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Based on observations, interviews, record review, and review of facility policy, it was determined that the facility failed to ensure the protection from physical abuse and harassment for one (1) out of ten (10) patients, (Patient (P)1).

Observation of a security surveillance video recorded 10/04/2025, time unknown, revealed Patient 1 (P1) lying on the floor in a main corridor being kicked in the upper right leg by (PSA)6. Further review of the surveillance video revealed PSA6 returned to the unit without a staff member or security escort on two additional occasions that same day after being escorted off the unit once the allegations of the incident were reported.

The findings include:

Observation of a security surveillance video dated 10/04/2025 no time stamp recorded, showed a video for a total of 39:00 minutes over the unit's main hallway. The video revealed Patient 1 (P1) lying on the floor and being kicked in the upper right leg by (PSA)6. Further review of the surveillance video revealed PSA6 returned to the unit without a staff member or security escort on two additional occasions, the first time approximately five (5) minutes after being removed from the unit and the second time approximately fifiteen (15) minutes after being escorted off the unit once the allegations of the incident were reported.

Review of a facility policy titled, "Patient Rights and Responsibilities", revised 08/2025, revealed the facility will inform patients or their representatives of their rights in advance of furnishing or discontinuing patient care whenever possible, these rights include but are not limited to the patient's right to be free from abuse and harassment.

Review of a facility policy titled, "Reporting Patient Abuse, Neglect, and Exploitation", reviewed 04/2021, revealed each facility employee is expected to be aware of the facility's responsibility to the patients served and to be constant in efforts to safeguard their well-being. Further review of the policy revealed staff should intervene immediately to ensure patient safety and the alledged employee shall be removed from direct patient care pending the outcome of the facility's internal investigation.

Review of a facility policy titled, "Incident Investigations", revised 11/2020, revealed all employees alledged to have committed an incident involving allegations of abuse, neglect, or other serious occurrences or events with potential to cause harm will be moved immediately to a non-direct care position for the duration of the investigation. A staff member will accompany the employee alledged to have committed these incidents to the employee's supervisor's office, and if the employee is not immediately cleared or immediately assigned to work in a non-direct care area they will be escorted from the facility by security staff or a nursing supervisor/coordinator. The policy further stated any staff member that has been pulled from direct care due to an incident allegation will not be allowed in any patient care area for any reason until notified by his or her supervisor. The supervisor will ensure the facility director or designee has been notified that the employee has been pulled from direct patient care. If the employee enters a patient care area while pulled from direct care the unit nurse will immediately contact security to escort the employee off the unit, the nusring coordinator and risk management will be notified, and the employee will be subject to the appropriate disciplinary action.

Review of a facility document titled, "Incident Report", dated 10/04/2025 at 6:41 AM, revealed a staff member reported that PSA6 was observed kicking Patient 1 in the leg once while patient was sitting in floor. Further review of the incident report revealed PSA6 was removed from care and P1 was assessed by nursing and determined to have no injuries and denied any pain at that time.

Review of a facility document titled, "Final Expanded Investigative Report", provided to the State Survey Agency (SSA) on 10/10/2025 revealed the facilty substantiated the allegation of abuse committed by PSA 6.

Review of facility document titled "Facesheet" revealed (Patient (P) 1) admitted to the facility on 08/24/2025 with diagnoses that included Major Neurocognitive Disorder, Bipolar Disorder, and Intellectual Disorder.

In an interview with Patient Support Associate (PSA) 3 on 10/08/2025 at 3:20PM, she stated she was on the unit at the time but did not visually witness the incident. She stated that she was with another patient doing 1:1 observation. She further stated PSA 6 "forgot something" on the unit after he had been removed from care due to the incident allegation so he came back through the unit without an escort to retreive the items and he stated to her and another staff member sitting at the desk that the Shift Coordinator said for him "not to worry about it".

In an interview with Patient Support Associate (PSA) 1 on 10/10/2025 at 1:00 PM, she stated she has been employed at the facility since 08/11/2025. She stated on Saturday around breakfast, staff had passed out breakfast trays and P1 came and sat down in the wrong spot at a table where someone else's breakfast had been placed. She stated she told P1 that he needed to go and sit somewhere else because that was someone else's spot, but he did not comply. She stated PSA6 then came over to them and started to yell at P1 to get up and proceeded to grab P1 up by his shoulder and P1 was beginning to fall from the chair. PSA1 stated PSA6 continued to push P1 down towards the floor. She stated P1 and PSA6 continued to go back and forth with each other and that is when she saw PSA6 "kick" P1 in his right leg in an area above the knee. She stated P1 was screaming "abuse" and that he was "going to tell on" PSA6. PSA 1 stated before the patient had the opportunity to tell anyone she went to the office and reported the incident to the nurse on duty. She stated the nurse called the shift coordinator right away she stated she told him to go into office and PSA6 asked "for what", and as he was asking this, the nurse on unit was coming around the corner she told him to "ask her, (PSA 1) what was going on because she was the one that said something." She stated this statement was made in front of other staff members, the alleged perpatrator, and shift coordinator. PSA1 stated this situation made her feel very uncomfortable because the nurse just let everyone know who made the report. She stated PSA6 started to ask her "what did he do", she stated she did not respond. PSA 1 stated at that time the coordinator had told PSA6 to leave the unit. She stated after he left the unit he returned to the unit and would walk close towards where she was sitting 1:1 with the patient that he was originally assigned to because she took over his assignment once he was removed from the floor. PSA1 stated each time when PSA 6 returned to the unit he would walk close towards where she was sitting 1:1 with the patient, and give her "dirty looks" as form of intimidation, and that he was talking to the other co-workers about the event from what she could gather. PSA 1 stated that she was afraid at first because he was coming back and forth to the unit after being escorted off that she may not be able to continue working here but stated she was assured by the risk management that he would not be allowed to come back anymore. PSA 1 stated she has worked with PSA 6 a couple times before and that PSA6 always has a negative attitude when it comes to working and is very negative towards the patients. She stated when she got off work that she went upstairs to make her report and tell someone about what happened but the night shift coordinators had already left for the day and there was no one up there to take her report. She stated she asked the day shift coordinator and he told her they were gone. She stated at first she was really concerned and she thought about quitting her job behind him being able to get back on the unit because that made her feel uncomfortable because if he had no problem doing what he did to a patient she felt like no telling what he would do to her. She stated she was the one who had to call Risk Management, and notify them of the patient returning to the unit as well.

In an interview with Patient Support Associate (PSA) 6 on 10/10/2025 at 12:53 PM, he stated around 5:30-6:00AM, he observed P1 trying to take another patient ' s food where he had sat down at the table at a tray that he had mistaken for his own. He stated he had been informed for the past week the patient had been getting on floor as a behavior. He stated while P1 was on the floor he tried to grab a banana off the tray. PSA 6 stated he went and scooted the tray all the way over out of the patient's reach and that is when P1 tried to "kick" at him and PSA1 stated he "blocked" the kick with his leg. PSA 6 stated in an effort to stop his leg the second time, PSA 6 lifted up his leg to meet his leg with P1's leg and stated no pressure was involved or anything. He stated after that he went back to the desk and sat down and the nurse came out and told him to stay in the office, but he was on a 1:1 and because of that he stood in the doorway to watch that patient. PSA 6 stated the TPCA came up to the unit and asked him did he have any personal belongings and he got his things went to the coordinators office and made a "pink slip" (leave form) and that is when she stated that he was being pulled from care and that he would be escorted out of the building. PSA 6 stated that the Shift Coordinator did not state who would be escorting him out. He stated he sat there for a while outside the shift coodinator ' s office for about 30 minutes and watched the TPCA and the Shift Coordinator for nights both leave at the end of their shift. He stated that he got tired of sitting there so he asked the dayshift coordinator if he could go home and he said "yes he could go ahead and leave" so he left. PSA 6 stated that he did go back up to the unit after he was pulled from care because he had forgot his "juice" and wanted to go retrieve it. He stated that he was not told that he had officially been pulled yet they just told him to go sit outside her office door for a second while they went in the office and talked. PSA 6 stated he was notified on Tuesday that his contract had been terminated.

In a telephone interview with Registered Nurse (RN) 1 on 10/08/2025 at 4:05 PM, she stated the incident was reported to her by PSA 1, who was the employee that actually observed the incident and she stated that her report was based off the information reported to her and she reported it to her supervisor and pulled PSA6 from the floor. She stated PSA 1 came into the office and told her that P1 had gotten kicked by PSA 6. She stated that she didn' t hear any commotion of any kind before or after the incident and was not aware of anything until PSA 1 came to her and reported it. She stated she told him that he needed to go and sit in the office and wait for her and PSA 6 stated "ok". RN 1 stated she went to go put some things in the medication room and by the time she came out the TPCA had showed up and was taking PSA 6 off the unit. She stated at that time the staff member was asking why he was being removed and what did he do, but the events were happening so fast she did not have time to explain to him why and that the shift coordinator was going to explain it to him. She stated she did not see or hear him return to the unit, but was told that he did indeed return to the unit when she went to provide her witness statement to Risk Management. RN 1 stated staff is not to return to the unit after they have been removed due to an abuse allegation. She stated there shouldn' t have been any reason for PSA 6 to come back to that unit. She stated if there was something that he had forgotten someone else could have retrieved the items for him. She stated she is not aware of any other incidents with the staff member and other patients stated that this unit was not her usual assignment and that she had only worked with this crew twice since she has worked at the facility.

In an interview with the Therapeutic Program Coordinator Assistant (TPCA) on 10/08/2025 at 5:15 PM, she stated that she recalled that morning of the incident, after around 6:00 AM she was asked by the shift coordinator to go retrieve a staff member and bring him down to her office. She stated the staff member went in to the shift coordinator 's office and she waited outside and they came out and the shift coordinator asked her to escort him out of the building. She stated she cannot recall what time she was asked to do this but she remembered leaving work for the day at 6:30AM. She stated that when she left PSA6 was sitting in the chair outside of the shift coordinator's office which was located in an area where everyone signs out for the day. She stated she thought he was waiting for a ride home. The TPCA stated she normally would be the person to walk them (staff) out and watch them leave and go out the door. She further stated was unaware that PSA6 had returned to the unit after being pulled from direct care. She stated she left him in the care of the shift coordinator before she went home and that PSA6 knew he was not to return to the floor after being pulled from care. She stated PSA6 was just pulled from care a week ago and had just returned to the floor that very day he was pulled from care again.

In an interview with the Shift Coordinator on 10/08/2025 at 2:50 PM she stated the unit nurse called her that morning and stated a staff member informed her that PSA 6 had kicked P1. She stated she then called the Risk Management staff on-call that day and reported the incident to him. She stated she then had the TPCA go to the unit and escort PSA 6 to her office so that she could go over the "pull" paperwork with him. The Shift Coordinator stated at this time PSA 6 was informed that he was not to be in any patient care areas, and that if he wanted to get his hours in that he could use time off or work in another part of the facility away from patients and that someone from management will be getting in touch with him. She stated the TPCA escorted him off the property after that. The Shift Coordiantor stated that she was not informed that PSA 6 went back down to the unit after being pulled from care, and that it is not normal protocol for them to be on a unit after being pulled from care. She stated there is no way she can actually check and verify if anyone leaves. She stated they walk the staff out but she has no way of actually knowing if the staff truly leave the facility or not. She stated that they don ' t take their badges or anything just in case the staff member decides they want to work another department while the investigation is being conducted.

In an interview with the Security Supervisor on 10/10/2025 at 9:20AM she stated the nursing coordinator is the one responsible for escorting the staff member out the door, and the only time they call them is if the staff member is giving them a hard time about not leaving. She stated that they will request a couple security guards to come and help them with escorting the person out then, but in this case it is up to nursing to ensure that they are off the property and they let them know that particular person is not allowed back on the property.

In an interview with Investigator 2 on 10/09/2025 at 2:55PM he stated that he initiated the investigation that Saturday morning. He stated he received a phone call from either the shift coordinator or the nurse from the unit the incident occurred on reporting what happened. He stated she stated to him that another staff member witnessed PSA6 kick a patient. He stated that he asked the nurse to go and assess the patient and asked them what happened and he stated that he never got a return phone call from her. He stated he called the shift coordinator that was on shift later that morning and he stated that he asked him to go and see the patient and do an assessment and check and see how he was. He stated that he followed up with him and the patient did not have any injuries. He stated that later on that morning he received a phone call around 9:00 AM from PSA 1 who had reported the incident and she stated that she was concerned about PSA 6 being able to return to the unit after he was removed and he stated that he reassured her that PSA 6 would not be returning to that unit, and that he requested she write a statement of what happened. He stated he turned over the investigation to Investigator 3 to complete. He also stated that under no circumstances should PSA 6 have been able to come back into any patient care area after being pulled from a care area and that he should have had a staff member with him and escorted off the property right away. He stated that he sent an email to the Nursing Department staff about the staff member returning to the unit when he learned of the incident.

In an interview with Investigator 3 on 10/08/2025 at 6:45 PM she stated Investigator 2 initiated the investigation on Saturday as he was the on-call risk management staff for that weekend and she took it over on Monday when she returned to work. She stated she attempted to interview Patient 1 but due to his intellectual abilities he was not able to be interviewed. Investigator 3 stated that she notified Patient 1's Social Worker and he stated to her that he would contact the guardian. She stated she spoke with PSA 6 over the telephone and he denied the allegations made against him. Investigator 3 stated that she asked PSA 6 to provide her with a written statement but he never did. She further stated that the Risk Mangement Department addressed their concerns of PSA 6 returning to the direct care areas with the Nursing Department but they don't always provide them with an update on the corrective measure they take. She stated Risk Management will make recommendations and request for the identified problem's solution when warranted.


In an interview with the Director of Nursing (DON) on 10/10/2025 at 9:24 AM, She stated her expectations from nursing staff would be to ensure that patients are safe from abuse and harm and staff pulled from care after an allegation was escorted off the unit and no longer on facility grounds. She stated PSA 6 was terminated on 10/07/2025, the date that the investigation was officially substantiated. She stated that she did not know that PSA 6 had returned to the unit after he had been pulled from care. She stated they will have to meet with Risk Management, and the Facility Director to address possible policy changes about pulling the badge and keys of a staff member under investigation so that they are not able get around the building freely.

In an interview with the Facility Director on 10/10/2025 at 2:28 PM, she stated she gets an email as soon as a staff gets pulled from direct care. She stated Risk Management is still working on their investigation because she has not received a final copy to sign. Stated her expectations for any staff and not just nursing would be for them to make sure the patient is safe from any harm.