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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 23, 2025
Corrected date: July 2, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an Abbreviated Survey, (NY 095), the facility failed to protect resident's right to be free from physical abuse. The facility did not ensure each resident was free from abuse for 1 out of 3 of residents sampled (Resident #1). Specifically, on 1/24/2022 at approximately 05:10 AM, Certified Nurse Assistant #1 (CNA #1) pushed, hit, and restrained Resident #1 to the floor. Resident #1 was transferred to the emergency room (ER) for an assessment. The findings are: The facility's Policy and Procedure entitled Abuse, Neglect, and Mistreatment of [REDACTED]. The Facility's Investigation Report dated 11 /24/2021, documented on 11/24/2021 at 5:10 AM, CNA #1 was giving coffee to the residents. When CNA #1 give coffee to Resident #1, Resident #1 hit CNA #1's hand and spilled the coffee on the floor. CNA #1 restrained Resident #1 on the floor to prevent Resident #1 from hitting again. CNA #1 refuse to release Resident #1 until the Security Guard #1 (SG #1) or Police officer arrived. The SG #1 came, and CNA #1 released Resident # 1. Resident #1 who was alert and oriented sustained superficial scratches on the face with minimal bleeding. CNA #1 was noted with a swollen left eye and complained of pain in both the knee and right little finger. The emergency number 911 was called, and Police Officers came and investigated the incident. CNA #1 was taken to the emergency room (ER #1) and the Resident #1 was taken to ER # 2. CNA #1 was suspended pending further investigation. The Surveillance Camera #1, dated 1/24/2022, with no time stamp or voice recording was reviewed with the Director of Social Service #1 (DSS #1 ) on 5/2/2022 at 11:11 AM. During review of Camera #1: The recording started with Resident #1 was standing in front of the food pantry room behind Resident # 2. Resident #2 got coffee from CNA #1 and left. CNA #1 was not visible, only CNA's hands were visible from the food pantry room. Resident #1 handed a cup to CNA #1 in the food pantry room. Resident #1 was seen waving hands toward the food pantry entrance, and then walked away. CNA #1 came out of the food pantry with a cup in the hand and approached Resident # 1. Resident #1 smashed the cup from CNA #1's hand to the floor. There was no liquid in the cup. CNA #1 was standing in the hallway. Resident #1 pick up the cup from the floor and approached CNA #1 with an aggressive posture. CNA #1 walked toward Resident # 1. Resident #1 pushed CNA # 1. CNA #1 grabbed Resident #1 's shirt with both hands and pushed Resident #1 in the hallway, away from the camera view. Resident #2 was seen seated in the wheelchair wheeling down the hallway. At 3:11 minutes of recording time, Resident #1 was seen on the floor and CNA #1 was sitting on the top of the Resident #1, trying to restrain Resident # 1. Resident #1 was fighting with CNA #1 using both hands and legs to free themselves. CNA #1 got control over Resident #1 and held Resident #1's neck to the floor. CNA #2 was seen running in the hallway, and two other residents were standing around Resident #1 and CNA # 1. At 4:56 minutes of recording time: The Registered Nurse Supervisor #1 (RNS #1 ) came from the elevator. CNA #1 continued to hold Resident #1 on the floor. RNS #1 bend over and touched CNA #1 on the shoulder. CNA #1 continued to hold Resident #1 on the floor. At 7:02 minutes of recording time: SG #1 came to the unit and was seen talking to CNA # 1. At 7:37 minutes of recording. SG #1 held Resident #1's hand and CNA #1 released Resident #1 and got up. The Surveillance Camera dated 1/24/2022, revealed that CNA #1 held Resident #1 on the floor for 4. 26 minutes until the SG #1 intervened. CNA #1 left the scene and went toward the nursing station. SG #1 assisted Resident #1 to get up. The Surveillance Camera #2 dated 1/24/2022 showed the scene from another hallway: At 00:12 minutes: Resident #1 smashed a cup from CNA #1's hand. Resident #1 picked up the cup and approached CNA #1 with an aggressive posture. CNA #1 moved toward Resident #1 and appeared to be talking to Resident # 1. Resident #1 pushed CNA #1 in the chest. CNA #1 grabbed Resident #1's shirt and pushed Resident #1 down the hallway and against the wall. Resident #2 was trying to intervene by approaching in the wheelchair. CNA #1 looked at Resident #2 and continue to hold Resident # 1. Resident #2 wheeled away from camera view. Resident #1 tried to push CNA #1 away and they started wrestling in the hallway. CNA #1 pushed Resident #1 against the wall again. They both lost their balance, knocked over a cup of coffee, and fell on the floor. Resident #1 landed on the floor and CNA #1 fell on top of Resident # 1. Resident #1 was hitting CNA #1 in the head. CNA #1 was trying to hold Resident #1 down. CNA #1 struck Resident #1 on the head. CNA #1 held Resident #1 on the floor until the Security Guard #1 intervened. Resident #1 with [DIAGNOSES REDACTED]. The Minimum Data Set 3. 0 (MDS, a resident assessment tool) dated 12/10/2022, documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score 15 out of 15, indicating Resident #1 's cognitive status was intact. A Comprehensive Care Plan (CCP), for Behavior Symptoms: Physical Abuse initiated dated 01/24/2022 documented that Resident #1 exhibited physically aggressive behavior towards staff/others. The documented interventions included identifying patterns of behavior, notifying behavioral changes to a Medical Doctor (MD), and referring to a Psychiatric consult, social service, and follow-up. A physician's orders [REDACTED].#1 is on [MEDICATION NAME] 40 mg daily. A Progress Note, written by RNS #1, dated 01/24/2022 at 08:45 AM, documented : Behavior/Physical Abuse on 1/24/22 at 5:10 AM. Staff (CNA #1) were in the pantry giving coffee to the residents. Resident #1 asked for coffee and CNA #1 asked how Resident #1 wanted the coffee, either regular sugar or with milk. While CNA #1 was giving the coffee to Resident #1, Resident #1 hit the CNA #1's hand that was holding the coffee and spilled the coffee onto the floor. CNA #1 restrained Resident #1 on the floor. When RNS #1 went to the unit, CNA #1 told RNS that Resident #1 will not be released until the SG #1 or the Police arrived. The SG #1 came immediately, and CNA #1 released Resident # 1. CNA #1 has swollen left eye and complained of pain in both knees and right little finger. Resident #1 has scratches on the face with minimal bleeding. The Incident was called to Emergency number, 911 and Police officers responded and interviewed Resident #1 and the CNA # 1. CNA #1 was taken to ER #1, and Resident #1was taken to ER # 2. The incident was reported to the Director of Nursing #1 (DON #1) and Medical Provider. Resident #1's family was called and informed about the allegation. A Psychiatry consult note dated 12/5/2021, documented, that Resident #1 with a history of substance use disorder and was reporting feeling weak with poor appetite. Resident #1, Denied any suicidal/homicidal ideations or any perceptual disturbances. There was no evidence of substance withdrawal, substance use disorder, or poor social support. A Certified Nurse's Assistant (CNA) Accountability Record dated 1/2022, documented that Resident #1 was monitored for verbally abusive behavior. A review of the in-service record revealed the most current in-service on Abuse for CNA #1 was dated 7/11/2019-9/12/2019 During an interview on 5/2/2022 at 12:46 PM, accused CNA #1 stated that he/she is currently on Work Compensation insurance due to the incident with Resident # 1. CNA #1 stated that on the day of the incident he/she worked the 12-8 AM shift. Resident #1 was not familiar to CNA #1 due to a recent in-house transfer. CNA #1 stated that from 5 AM- 6 AM they were serving coffee to residents in the pantry room. Resident #1 was the last resident who asked for coffee. CNA #1 asked Resident #1 how his/her coffee would like the coffee. Resident #1 answered light and sweet, CNA #1 decided to close the pantry room and have someone else assist Resident # 1. Resident #1 asked for the coffee, but CNA #1 felt that it is not normal for Resident #1 to talk to CNA #1 in that manner. CNA #1 gave the cup back to Resident #1 and he/she smashed the cup from CNA #1 hand. Resident #1 also said that he/she should smack CNA # 1. CNA #1 stated that he/she told Resident #1 to go ahead. CNA #1 stated that he/she would never turn their back on Resident # 1. CNA #1 stated that he/she did not feel safe turning his/her back because he/she did not know what Resident #1 can do to him/her or other residents. CNA #1 stated that Resident #1 hit him/her in the face. CNA #1 tried to hold Resident #1's hands. There was Resident #2 sitting in the hallway in the wheelchair. CNA #1 stated that he/she and Resident #1 were wrestling in the hallway. CNA #1 got Resident #1 against the wall and tried to hold his/her hands. Resident #1 used his/her head to hit CNA # 1. CNA #1 stated that he/she felt dizzy. CNA #1 took his/her foot and swept Resident #1 to make Resident #1 fall on the floor. CNA #1 stated that they both fell on the floor and CNA #1 was on the bottom. Resident #1 was on the top. CNA #1 managed to get on top of Resident #1 and held Resident #1 to the floor. CNA #1 stated that he/she did not hit Resident # 1. CNA #1 was yelling for help. CNA #2 came (CNA #2 was on break at that time) and went to get help. The RNS #1 came and told CNA #1 to let go of Resident # 1. CNA #1 stated that he/she refused until SG#1 came. CNA #1 stated that he/she was afraid of Resident # 1. When the SG#1 came on the floor, CNA #1 released Resident # 1. The RNS#1 called the Police. The Police came and CNA #1 was taken to the hospital. CNA #1 stated that he/she has a protective order against Resident # 1. CNA #1 stated that he/she received in-service on abuse prohibition 3 weeks prior to the incident and has a certificate of completion. During an interview on 5/2/2022 at 12:00 PM, DSS #1 stated that CNA #1's action was abuse. CNA #1 should not have provoked Resident #1, and CNA #1 had an opportunity to get away from Resident #1 and call for help. CNA #1's actions were not appropriate. The staff are not allowed to restrain residents. DSS #1 stated that Resident #1 was arrested in the hospital, and no one knew where they took him/her. The facility called the Police again to find resident #1 and was told that Resident #1 was in the custody of the police. Resident #1 returned to the facility the next day on his/her own but refuse to stay in the facility. Resident #1 was discharged to the housing program and to continue the [MEDICATION NAME] program at the outpatient clinic. During an interview on 5/2/2022 at 2:00 PM, Resident #2, stated that he/she remember the incident. It was coffee time. Resident #1 came late and did not have a cup. Resident #2 went to his/room and give Resident #1 a cup. Resident #1 was arguing with a lady (CNA #1) who was serving coffee. CNA #1 asked Resident #1 why he/she has an attitude. Resident #1 answered that he/she does not want to argue, he/she just wants his/her coffee. CNA #1 said that he/she does not have coffee for Resident # 1. CNA #1 closed the pantry door and give a cup to Resident # 1. Resident #1 took the coffee and smacked the cup from CNA #1's hand. Resident #2 stated that he/she went to his/her room to get his coffee and when return he/she observed Resident #1 on the floor and CNA #1 was on the top of Resident # 1. CNA #1 was strong and hold Resident #1's arm across so that he/she could not move. Resident #1 was saying let me go, let me go. CNA #1 did not let him/her go. CNA #1 told Resident #2 to go and get help. Resident #2 went and got another resident. Then the RNS #1 told CNA #1 to let Resident #1 go. The SG #1 came and CNA #1 let Resident #1 go. Police came to the unit. Resident #2 stated that he/she did not see CNA #1 hit Resident # 1. During an interview on 5/12/2022 at 4:12 PM, RNS #1 stated that they worked the 12-8 AM shift. RNS #1 was called from the unit by CNA #2 to come immediately to the floor because there was a fight. CNA # 2 did not specify who was fighting. RNS #1 immediately went to the unit, from the elevator RNS #1 saw that Resident #1 was down on the floor and CNA #1 was on the top of Resident # 1. RNS #1 told CNA #1 to release Resident # 1. CNA #1 told RNS #1 that he/she was not going to release Resident #1 until RNS #1 calls the police or SG # 1. RNS #1 called SG#1 who responded immediately. CNA #1 then released Resident # 1. RNS #1 called 911 emergency number. Resident #1 had superficial scratches with minimal bleeding on the face. RNS #1 attempted to conduct a physical assessment on Resident #1, but Resident #1 refused a full body assessment. When Police Officers arrived, Resident #1 was interviewed by one Police Officer, and CNA #1 was interviewed by another Police Officer. CNA #1 was taken to the ER and Resident #1 was taken to another ER. RNS #1 notified DNS #1 . Then RNS #1 reviewed the camera and saw that Resident #1 knocked the cup from CNA #1's hand. CNA #1's action was not appropriate. RNS #1 stated that he/she started the incident report. RNS #1 stated that he/she is not willing to testify. During an interview on 5/12/2022 at 5:00 PM, SG #1 stated that they received a call from the unit that Resident #1 and CNA #1 are fighting. When SG #1 reached the unit, CNA #1 had pinned Resident #1 to the floor. SG #1 stated they were separated. When SG #1 reviewed the camera, it was observed that Resident #1started the fight by pushing CNA # 1. SG #1 stated that CNA #1 had the opportunity to get away from the Resident #1 and call for help. SG #1 stated that he/she was not willing to testify. During an interview on 5/12/2022 at 3:30 PM, the DNS #1, stated that the incident dated 1/24/2022 was investigated by prior DNS #1 and Administrator # 1. CNA #1 was currently not working and on medical leave due to an incident with Resident # 1. During an interview on 5/03/2022 at 2:40 PM, Administrator #2 stated that the prior Administrator #1 and DNS #1 left abruptly. The former DNS #1 felt it was abuse and reported the allegation to to New York Department of Health (NYDOH). During an interview on 6/3/2022 at 1:00 PM, former DNS #1, stated that they were notified by the night supervisor that CNA #1 restrained Resident #1 to the floor and did not let the resident go until SG #1 came to the unit. Resident #1 was begging CNA to let him/her go, but CNA #1 refused. When DNS #1 reviewed the camera they concluded that CNA #1 was abusive to Resident # 1. Administrator #1 reported the allegation to NYDOH. DNS #1 also stated that they called Police twice. First, when the incident happened, and the second time after viewing the camera surveillanceand. 415. 4(b)(1)(i) | Plan of Correction: ApprovedJune 19, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 1 was assessed by a License nurse on 5/7/2025 and showed no signs and symptoms of injury or change of condition and MD assessment was also conducted on 5/7/2025, no sign of any visible injury, no change in behavior and no change in mental status. Care plans were updated to ensure interventions are in place to prevent abuse. Resident was assessed by Social Services on 5/8/2025 and noted with no apparent distress, talking, laughing, and smiling. The CNAs involved were taken off duty immediately. CNA #1 was terminated, CNA#2 and CNA #3 were suspended without pay. Police were called by the Administrator and DON met with the family member to provide information and reassurance/emotional support. Report number was assigned. The Abuse policy was updated, and Abuse posters were updated. Staff were educated by the in-service department about the updated policy and abuse poster and this was completed by 5/23/ 2025. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be affected by this finding. The QA Committee updated and approved the revision of Abuse and Neglect Policy and Procedure to include See Something, Do Something, Report Immediately??ÿ. The QA Committee also met on 6/11/2025 to discuss root cause analysis of possible reasons why they deficient practice occurred, and Consultant advised on findings. The Abuse poster was updated and written in different languages and posted throughout the facility, so employees, residents, and visitors are aware of the policy. Anyone who does not follow abuse policy and procedures will face disciplinary action up to and /or including termination. Guardian Angel Department Head unit rounds will be conducted once per week to help prevent identify problems that may lead to potential abuse and report any negative findings during morning report will also be implemented. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur All staff were educated by the in-service department using the revised policy and procedures on Abuse, neglect, exploitation, and Misappropriation of resident property by 5/23/ 2025. The facility obtained an outside consultant not employed by the facility to help develop an acceptable directed plan of correction and in service by 6/12/ 2025. Enhanced training on how to handle behavioral situations with residents who have cognitive impairment/Dementia and in-service about Abuse will be provided by the outside consultant 6/18/2025 ?ö?ç?ú 6/20/2025 and additional zoom trainings will be provided on 7/1/2025 and 7/2/2025 for staff on vacation or leave based on the findings of the QAPI Committee. Anonymous suggestion box for employees and families was also created. Nursing assignment is now rotating every 6 months. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice DON or designee will monitor compliance to the revised policy on Preventing Abuse, neglect, exploitation, and misappropriation of resident property??ÿ and the DP(NAME) to ensure staff are properly addressing and promptly reporting abuse or allegations of abuse following facility Policy and Procedures. DON or designee will report progress of this QAPI to the QA Committee until significant compliance is achieved. Nurse Supervisors will continue auditing the residents in all units. Audit tool #1 and #2 will be utilized. It will be done weekly for a period of one month. Then once a month for a period of three months and then quarterly check will be in place until significant compliance is achieved. DON or designee will report findings to the QA committee for monitoring until significant compliance is achieved. Administrator or designee will monitor the anonymous Suggestion Box and address anything placed inside the box. This will continue for a period of one year. Guardian Angel Department Head room rounds will occur once a week to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. This will be monitored by the Administrator or designee for a period of one year in QA Committee. The date for correction and the title of the person responsible for correction of each deficiency The Administrator, Director of Nursing, Nursing Supervisors or designee will be responsible for the correction, and they will be completed by 7/2/ 2025. |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 23, 2025
Corrected date: July 2, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview during an abbreviated survey (NY 105), the facility failed to implement Abuse/Neglect policies to prevent, protect and report an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, the facility failed to protect Resident #1 from Certified Nursing Assistant #1 who was observed restraining both hands of Resident #1 and hitting them in the head. This incident was observed by Certified Nursing Assistants #2 and #3 who were in the hallway at the time of the incident and did not identify, correct, intervene or report the occurrence of abuse. Additionally, the incident was reported by a visitor on 05/06/2025 to Unit Liaison #1 who did not report the incident to their supervisor (Unit Liaison #2) until 05/07/ 2025. This allowed Certified Nursing Assistants #1, #2, and #3 to have continued access to Resident #1 and the other 436 Residents in the facility. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99 indicating severe impairment for decision making. The review of the facility policy entitled, Abuse, with a revision date of 03/2024, documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights, dignity and respect are maintained. The policy further documented all staff are responsible for reporting abuse, intervene immediately to safeguard resident if abuse, neglect, mistreatment or misappropriation of property has been observed. Report incident of actual or alleged abuse, neglect or mistreatment to charge Nurse or Supervisor immediately. Review of the facility video surveillance with the Administrator, Director of Nursing and Risk Manager on 05/19/2025 at 10:28 AM, revealed that on 05/04/2025 at 3:59 PM Resident #1was in the hallway sitting in a wheelchair outside of a resident room. Certified Nursing Assistant #2 is observed standing at the nurse's station and Certified Nursing Assistant #3 was observed in the hallway taking vital signs of another resident. Certified Nursing Assistant #1 was observed pointing their finger in the face of Resident # 1. Resident #1 responded by striking the hand of Certified Nursing Assistant #1 twice. Certified Nursing Assistant #1 responded by striking Resident #1 across the head and proceeds to hold both of the resident's hands down towards the wheelchair. Review of the Resident Accident/Incident Report dated 05/07/2025 at 10:30 AM documented that on 05/06/2025 an anonymous visitor reported to Unit Liaison #1 that they witnessed Staff had an inappropriate encounter with Resident #1 on 05/04/ 2025. The Accident Incident Report further documented Unit Liaison #1 did not report this information to Unit Liaison #2 until the morning of 05/07/ 2025. The Accident/Incident Report further documented while reviewing the camera, it was observed that Certified Nursing Assistant #1 had inappropriate contact with Resident # 1. It was also noted that two (2) additional staff members were in the hallway at the time of the incident looking towards the incident. The facility investigation documented that Certified Nursing Assistants #2 and #3 denied seeing the occurrence. During an interview on 05/19/2025 at 12:53 PM with Unit Liaison #1, they stated they received a call on 05/06/2025 at approximately 5:30PM-6:00PM from an unidentified caller who stated that on Sunday 05/04/2025, when the caller was visiting the facility, they heard screaming and when they came out of the room they were in, they observed staff hitting Resident #1 in the head. Unit Liaison #1 stated on the morning of 05/07/2025, they reported this to Unit Liaison # 2. They further stated that they should have notified the supervisor immediately about the incident. Multiple telephone call attempts to reach Certified Nursing Assistant #1 on 05/19/2025 at 1:30 PM and 2:00 PM, as well as on 05/20/2025 between 10:30 AM and 2:00 PM were unsuccessful. Phone call messages were not returned, and a letter was sent, with no response to the letter. Multiple telephone call attempts to reach Certified Nursing Assistant #2 on 05/20/2025 at 2:00 PM and 3:00 PM were unsuccessful. A letter was sent with no response. During an interview with Certified Nursing Assistant #3 on 05/19/2025 at 3:16 PM, they stated that on 05/04/2025 they worked 3:00 PM - 11:00 PM as their regular assignment and they stated Resident #1 was on their assignment. They further stated Resident #1 is not combative and does not hit staff during care. They stated on 05/04/2025 they were taking vital signs for another Resident and did not notice Certified Nursing Assistant #1 hit Resident # 1. They stated they heard Resident #1 yelling but did not look to see what was going on. When asked about the video surveillance where they were observed looking in the direction of Resident #1, Certified Nursing Assistant #3 stated they did not recall. During a telephone interview with Licensed Practical Nurse #1 on 05/19/2025 at 1:51 PM, they stated that on 05/04/2025 at approximately 4:00 PM, while at the nurse's station, they heard screaming in the hallway and saw Certified Nurse Aide #1 removing a resident away from Resident # 1. Licensed Practical Nurse #1 stated they did not see anyone hitting Resident #1 and this was not reported by any staff in the hallway. Licensed Practical Nurse #1 stated if the staff saw any abuse, such as anyone hitting a resident, they should have informed the Nursing Supervisor immediately. When asked about the video surveillance not showing another resident in the proximity at that time, Licensed Practical Nurse #1 stated they did not see the video and could not recall. During an interview conducted on 05/19/2025 at 3:08 PM with the Director of Nursing, they stated the incident was reported by Unit Liaison #1 on 05/07/ 2025. The incident should have been reported as soon as the visitor reported what they saw. They stated during the investigation and review of the video surveillance they could see Certified Nursing Assistant #1 strike Resident # 1. They further stated during the investigation Certified Nursing Assistant #2 and Certified Nursing Assistant # 3 were seen facing the direction of the incident, however both denied seeing anything, and did not report any incident to the floor nurse or the supervisor. The investigation summary documented abuse did occur to Resident # 1. During an interview conducted on 05/19/2025 at 4:30 PM with the Facility Administrator they stated the incident should have been reported immediately. They further stated Certified Nursing Assistant #2 and #3 denied seeing abuse however are observed facing the direction of the incident. The Administrator stated the facility has a zero-tolerance policy for abuse. They further stated the staff should have intervened and protected the resident and reported immediately. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedJune 19, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 1 was assessed by a License nurse on 5/7/2025 and showed no signs and symptoms of injury or change of condition and MD assessment was also conducted on 5/7/2025, no sign of any visible injury, no change in behavior and no change in mental status. Care plans were updated to ensure interventions are in place to prevent abuse. Resident was assessed by Social Services on 5/8/2025 and noted with no apparent distress, talking, laughing, and smiling. The CNAs involved were taken off duty immediately. CNA #1 was terminated; CNA #2 and CNA #3 were suspended without pay. Police were called by the Administrator and DON met with the family member to provide information and reassurance/emotional support. Report number was assigned. The Abuse policy was updated, and Abuse posters were updated. Staff were educated by the in-service department about the updated policy and abuse poster and this was completed by 5/23/ 2025. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this finding. Risk manager screened all residents in the unit where Resident #1 resides, completed on 5/8/ 2025. No signs and symptoms of abuse noted. Then, two audit tools were created and utilized to assess random residents in all units. It was completed on (MONTH) 23, 2025. Alert residents that can be interviewed were interviewed using the audit tool #1 to check for abuse and the ones cannot be interviewed were checked for any sign / symptoms of abuse using audit tool # 2. If identified, an investigation will take place, and disciplinary action will be imposed. There were no other residents found to have similar findings. There was no indication of any abuse as a result of the audits. Administrator reviewed facility Self-Reported Accident / Incident Log and noted all were reported and investigations completed. All staff were in service on Abuse, Neglect, Exploitation and Misappropriation of property.??ÿ By 5/23/ 2025. Staff who are on leave or vacation will be in-serviced upon return. The facility also obtained an outside consultant not employed by the facility to help develop and implement an acceptable directed plan of correction and in-service. Enhanced training on how to handle behavioral situations with residents who have cognitive impairment/Dementia and additional education on abuse, neglect and mistreatment will also be provided by an outside Consultant 6/18/2025-6/20/2025 and additional zoom trainings will be provided on 7/1/2025 and 7/2/2025 for staff on vacation or leave based on the findings of the QAPI Committee. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur. The QA Committee updated and approved the revision of Abuse and Neglect Policy and Procedure to include See something, Do something, Report immediately??ÿ and the Abuse poster updated as well. The message is written in different languages for all residents/ visitors of the facility. All staff were given an in-service using the revised policy and procedures on Abuse, neglect, exploitation, and misappropriation of resident property??ÿ. Anonymous suggestion box for employees and families was created. Nursing assignment is now rotating every 6 months. Guardian Angel Department Head room rounds will occur once a week by managers or designees to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice DON or designee will monitor compliance to the revised policy on Preventing Abuse, neglect, exploitation, and misappropriation of resident property??ÿ and the Directed Plan of Correction to ensure staff are properly addressing and promptly reporting abuse or allegations of abuse following facility Policy and Procedures. Administrator will report progress of this QAPI to the QA Committee until significant compliance is achieved. Nurse Supervisors will continue auditing the residents in all units. Audit tool #1 and #2 will be utilized. It will be done weekly for a period of one month. Then once a month for a period of three months and then quarterly check will be in place until significant compliance is achieved. All findings will be reported by the DON or designee to QA committee for monitoring and ensuring significant compliance. Administrator or designee will monitor the anonymous Suggestion Box and address anything placed inside the box. This will continue for a period of one year. Guardian Angel Department Head room rounds will occur once a week to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. This will be monitored by the Administrator or designee for a period of one year in QA Committee. The date for correction and the title of the person responsible for correction of each deficiency The Administrator, Director of Nursing, Nursing Supervisors or designee will be responsible for the correction, and they will be completed by 7/2/ 2025. |