Every finding on record at Aperion Care Monroe

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment for 2 of 9 resident rooms and 1 of 1 sit to stand mechanical lift. The sit to stand mechanical lift was dirty and resident rooms had flies and gnats. (room [ROOM NUMBER], room [ROOM NUMBER], Sit to Stand mechanical lift) Findings include:1. On 6/18/26 at 10:45 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. On 6/19/26 at 9:50 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. On 6/22/26 at 10:50 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. 2. On 6/18/26 at 10:50 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/19/26 at 9:55 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/22/26 at 11:00 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. 3. On 6/18/26 at 1:46 p.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/19/26 at 10:02 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/23/26 at 11:12 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. During an interview on 6/23/26 at 12:40 p.m. the Administrator indicated the sit to stand lift foot platform needed cleaning and the gnats and flies in the resident rooms were in need of elimination. On 6/18/26 at 11:49 a.m., the Administrator provided the Resident Rights, revised 3/15/17, and indicated these were the resident rights currently used by the facility. A review of the Resident Rights indicated residents, .have the right to a safe, clean, comfortable, and homelike environment . 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure staff prepared food in accordance with professional standards for food service safety for 1 of 2 kitchen observations. This had the potential to affect 31 out of 31 residents served from the kitchen.Findings include:During a kitchen tour on 8/3/25 at 10:45 a.m., a large pork loin was observed thawing in the bottom of a three compartment sink with running water flowing onto the meat. The meat was not submerged in water and the water was flowing down the drain.During an interview on 8/6/25 at 12:25 p.m., the Dietary Manager indicated the cook should have had the meat in a deep pot while the water was running onto the meat. On 8/3/25 at 11:05 a.m., the Administrator provided the facility policy, Thawing Foods, and indicated it was the policy currently being used. A review of the policy indicated, . 4. Thawing foods under cool running potable water (This process is not recommended and should only be used in an emergency and if you cook food immediately) . b. Food items should be completely submerged under running water .3.1-21(i)(3)

Based on observations, interviews, and clinical records, the facility failed to ensure flies and gnats were not present in 1 of 10 resident rooms (Resident 5, Resident 6, Resident 25), sit to stand lift foot platforms were clean for 2 of 2 sit to stand lifts used by 3 residents (Resident 2, Resident 17, Resident 26), and exposed wires were covered for 1 of 4 communal resident bathrooms observed for environmental concerns. Findings include: 1. On 8/3/25 at 1:47 p.m., 8/5/25 at 2:20 p.m., and 8/6/25 at 10:15 a.m., gnats and flies were observed in the room of Resident 5, Resident 6, and Resident 25 on the privacy curtains, walls, bedside tables, and the residents themselves. During an interview on 8/16/25 at 10:17 a.m., Resident 6 indicated there were flies and gnats in the room all the time unless it was wintertime. During an interview on 8/16/25 at 10:18 a.m., Resident 25 indicated there were almost always gnats and flies in the room. He frequently fashioned a fly and gnat swatter out of paper to combat the pests. 2. On 8/3/25 at 9:45 a.m. and 2:50 p.m., and 8/4/25 at 9:30 a.m. and 1:05 p.m. debris and food crumbs were observed on the foot platform of a sit to stand lift on the East Hall and the foot platform of a sit to stand lift on the North Hall. 3. On 8/3/25 at 10:00 a.m. and 2:40 p.m., electrical wires with wire nuts on them were observed emerging approximately 8 feet high on the north wall of the southeast resident bathroom. During an interview on 8/4/25 at 1:15 p.m., the Administrator indicated the sit to stand lift platforms had debris and food crumbs on them and were in need of cleaning, and the wires emerging from the wall of the southeast resident bathroom required a cover. During an interview on 8/6/25 at 11:00 a.m., the Administrator indicated the room of Resident 5, Resident 6, and Resident 25 had gnats and flies and was in need of an effective plan to eliminate the pests. On 8/3/25 at 11:15 a.m., the Administrator provided the Resident Rights, undated, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .you have the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)

Based on interview and record review, the facility failed to ensure staff submitted a comprehensive assessment within 14 days of a resident's discharge for 1 of 15 residents reviewed for MDS assessments and timing (Resident 13).Finding includes: On 8/4/25 at 10:19 a.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to dementia, Alzheimer's disease, and sacral pressure ulcer. A 7/17/25 progress note indicated the resident was sent to the hospital for a bleeding sacral wound and was admitted after she had wound surgery to stop the bleeding. A 7/17/25 discharge MDS (Minimum Data Set) assessment was listed as 'in process' and incomplete. The assessment reference date (ARD) was 7/17/25. During an interview on 8/6/25 at 1:19 p.m., the Director of Nursing indicated the facility was aware of the incomplete MDS assessment and the corporate staff was working to complete it.

Based on record review and interview, the facility failed to ensure residents have the right to be informed of and participate in their treatment for 2 of 6 residents reviewed for unnecessary medications. (Resident 7 and Resident 33)Findings include:1. On 8/5/25 at 11:00 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder (a condition characterized by a combination of schizophrenia and mood disorder symptoms), psychosis (a mental health condition where a person experiences a disconnect from reality), generalized anxiety disorder, major depressive disorder, and dementia (a decline in mental ability severe enough to interfere with daily life).A review of the physician's orders indicated the following:On 7/8/25, an order for Lorazepam (a medication used to treat anxiety) 1 mg (milligram) twice daily was prescribed for generalized anxiety disorder.On 7/9/25, an order for Cymbalta (a medication used to treat depression) 60 mg once daily, to be taken with Cymbalta 30 mg to equal 90 mg, was prescribed for major depressive disorder.On 7/9/25, an order for Cymbalta 30 mg once daily, to be taken with Cymbalta 60 mg to equal 90 mg, was prescribed for major depressive disorder.A review of a psychiatry provider note, dated 7/8/25, indicated Cymbalta was increased to 90 mg on 7/8/25, due to resident refused all other medications for depressive disorder. The provider note also indicated Ativan (lorazepam) was increased to 1 mg twice daily on 7/8/25 for generalized anxiety.The clinical record lacked documentation that indicated informed consent was provided to the resident and/or the resident representative, regarding treatment options, risks, and benefits of psychotropic medication prior to the increase in psychotropic medications.During an interview with the DON (Director of Nursing) on 8/6/25 at 12:25 p.m., she indicated there was not an informed consent obtained prior to the increase of psychotropic medications. 2. On 8/5/25 at 1:45 p.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and major depressive disorder.A review of the physician's orders indicated the following:On 7/22/25 an order for Sertraline (brand name Zoloft, medication used to treat depression) 100 mg once daily was prescribed for major depressive disorder.A review of a psychiatry provider note, dated 7/22/25, indicated the resident's major depressive disorder, was persistent as evidenced by irritability. The provider also indicated Zoloft was increased to 100 mg daily on 7/22/25.The clinical record lacked documentation that indicated informed consent was provided to the resident and/or the resident representative, regarding treatment options, risks, and benefits of psychotropic medication prior to the increase in psychotropic medications.During an interview with the DON (Director of Nursing) on 8/6/25 at 12:25 p.m., she indicated there was not an informed consent obtained prior to the increase of psychotropic medications. On 8/6/25 at 12:40 p.m., the Administrator provided a copy of the facility policy named, Psychotropic Medication-Gradual Dosage Reduction, dated 2/1/18, she indicated this was a current policy used by the facility. A review of the policy indicated, .Informed consent shall be obtained as follows: a) Psychotropic medications shall not be administered without the informed consent of the resident or the authorized resident representative . d) Side effects and dosage of the medication shall be described .3.1-3(n)(2)

Based on observation, interview, and record review, the facility failed to ensure the resident's representative and physician was notified of significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 25)Findings include: During an interview on 8/3/25 at 1:44 p.m., Resident 25 indicated in the last month, he had lost weight. On 8/5/25 at 12:24 p.m., Resident 25 was observed to be eating lunch. On 8/5/25 at 11:09 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia and hypertension. Resident 25's weight indicated the following:-On 6/3/25, Resident 25 weighed 156 pounds -On 7/9/25, Resident 25 weighed 144 pounds which was a 7.69% weight loss in a month. -On 7/28/25, Resident 25 weighed 140 pounds. The care plan, dated 1/20/23, indicated Resident 25 was at nutritional risk due to schizophrenia. The intervention was to report to the physician as needed of significant weight loss of 5% or greater in a month and to weigh resident and record as ordered. The Nutrition Progress note, dated 7/10/25 at 10:17 am, indicated Resident 25's weight was 144 pounds on 7/9/25 which was a 7.7% weight loss in 30 days. He was on a mechanical soft diet with ice cream at lunch and dinner and double eggs at breakfast. The note lacked documentation the responsible party or the physician was notified of the significant weight loss. The progress notes dated 7/6/25 through 8/6/25 lacked documentation of the responsible party or physician notification of the significant weight loss. The clinical record lacked documentation of a Comprehensive Clinical Review meeting, dated for 7/16/25. The Comprehensive Clinical Review Meeting, dated 7/23/25 at 5:26 p.m., indicated the responsible party and nurse practitioner was notified which was 14 days after significant weight loss. During an interview on 8/6/25 at 10:08 a.m., the Director of Nursing indicated the responsible party would be notified of weight loss after the first weekly Comprehensive Clinical review meeting. During an interview on 8/6/25 at 11:33 a.m., DON indicated Resident 25's weight in June 2025 was 156 pounds and on 7/9/25 his weight was 142 pounds. The clinical record lacked documentation of the responsible party or physician notification of weight loss until 7/23/25. On 8/6/25 at 1:50 p.m., the Administrator provided the facility policy, Physician - Family Notification - Change in Condition, revised date of 11/13/18 and indicated it was the policy currently being used by the facility. A review of the policy indicated, The facility will inform the .notify the resident's legal representative .(C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . On 8/6/25 at 1:50 p.m., the Administrator provided the facility policy, Weights, revised date of 10/17/19 and indicated it was the policy currently being used by the facility. A review of the policy indicated, Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician . 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure an accurate assessment for 1 of 15 residents reviewed for MDS (Minimum Data Set) assessment accuracy. (Resident 27)Findings include: On 8/4/25 Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury (an injury to the brain caused by an external force) and major depressive disorder. A review of the physician orders dated 3/25/25, indicated Resident 27 was prescribed Alprazolam (a medication used to treat anxiety disorders) for a diagnosis of anxiety. The resident's MAR indicated this remained an active order. A review of the provider progress note, dated 6/10/25, indicated the resident had an active diagnosis of anxiety. A review of the Resident 27's care plan, dated 9/16/24, indicated the resident used anti-anxiety medications.A review of the Quarterly MDS assessment, dated 6/30/25, indicated anxiety was not marked as an active diagnosis. During an interview with the DON (Director of Nursing) on 8/6/25 at 9:40 a.m., she indicated the resident had an active diagnosis of anxiety disorder on 6/30/25. The DON indicated the Quarterly MDS assessment, dated 6/30/25, was marked no for a diagnosis of anxiety disorder and it should have been marked yes. During an interview with the Administrator on 8/6/25 at 11:30 a.m., she indicated the facility did not have a MDS policy and they utilized the RAI (Resident Assessment Instrument) tool to complete MDS assessments.A review of the RAI, Version 3.0 User's Manual, 10/2024, on 8/6/25 at 12:00 p.m., indicated for section I5700, Anxiety Disorder, .Diagnosis status: Active or Inactive is a 7-day look-back period .Ongoing therapy with medications or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potentially severe side effects in the last 7 days .3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure resident received nutritional supplement for a resident with an assessed weight loss for 1 of 3 residents reviewed for nutrition. (Resident 25)Findings include: During an interview on 8/3/25 at 1:44 p.m., Resident 25 indicated in the last month he had lost weight. On 8/4/25 at 12:42 p.m., Resident 25 was observed to be resting in his bed. His lunch tray was observed to be in his room with no ice cream on the lunch tray. On 8/5/25 at 12:24 p.m., Resident 25 was observed to be eating lunch. No ice cream was observed on his lunch tray or on his meal ticket. During an interview on 8/5/25 at 1:45 p.m., Resident 25 indicated he did not get ice cream on his lunch tray. On 8/5/25 at 11:09 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to schizophrenia and hypertension. The quarterly Minimum Data Set (MDS) assessment, dated 6/26/25, indicated Resident 25 was cognitively intact. Resident 25's weight indicated the following:-On 6/3/25, Resident 25 weighed 156 pounds -On 7/9/25, Resident 25 weighed 144 pounds which was a 7.69% weight loss in a month. The care plan, dated 1/20/23, indicated Resident 25 was at nutritional risk due to schizophrenia. The intervention was to provide supplements as ordered. The Nutrition Progress note, dated 7/10/25 at 10:17 am, indicated Resident 25's weight was 144 pounds on 7/9/25 which was 7.7% in 30 days. He was on a mechanical soft diet with ice cream at lunch and dinner and double eggs at breakfast. On 8/6/25 at 12:10 p.m., Resident 25 was observed to be feeding himself lunch. His tray was observed not to have ice cream. On 8/6/25 at 12:17 p.m., the Dietary Manager was observed to be placing a dish of ice cream on Resident 25's lunch tray. At that time, she indicated she forgot Resident 25's ice cream on his lunch tray. The ice cream was to come out on his lunch trays. On 8/6/25 at 1:50 p.m., the Administrator provided the facility policy, Weights, revised date of 10/17/19 and indicated it was the policy currently being used by the facility. A review of the policy lacked documentation of nutritional supplements. 3.1-46(a)(2)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization . (Resident 33) Findings include: Residents 33's clinical record was reviewed on 10/22/24 at 2:02 p.m. The diagnoses included, but were not limited to, dementia and fracture of the left femur. Resident 33's progress notes indicated the resident was sent to the hospital on 9/30/24. The clinical record lacked documentation the written notification of the Transfer and Discharge forms were provided to the resident and the resident representative. During an interview on 10/24/24 at 2:45 p.m., the Administrator indicated the forms were sent in writing to the resident representative but was not documented. On 10/25/24 at 12:09 p.m., the Administrator provided the facility's policy,Discharge Transfer of Resident, dated 11/28/12, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate sending the written notification required for a transfer and discharge to the resident and the resident representative. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure a resident with a physician order for a carbohydrate controlled diet received the correct diet for 1 of 1 resident reviewed for food. (Resident 35) Findings include: During an interview on 10/21/24 at 2:35 p.m., Resident 35 indicated he had been on a low carbohydrate (carb) diet while in the hospital. He was supposed to be on a low carb diet while in the facility but he had been getting meals with high carbs. For lunch today, he had ham salad on bread. He had gained weight since coming to the facility from eating too many carbs. During an interview on 10/22/24 at 2:37 p.m., Resident 35 indicated lunch today had been chicken and noodles but he was only able to eat the chicken because he was not supposed to have carbs. Resident 35's clinical record was reviewed on 10/22/24 at 2:43 p.m. The diagnosis included, but was not limited to, Type II Diabetes Mellitus. Physician orders, dated 9/1/24 through 9/30/24, for Resident 35 indicated . regular diet, regular texture, regular/thin consistency . A review on 10/25/24 at 12:10 p.m., of the Inpatient Hospital Discharge Orders, dated 9/27/24, for Resident 35 indicated, . Discharge Diet: 9/27/24, Low-carb diet . During an interview on 10/24/24 at 1:56 p.m., the Administrator indicated she had not known Resident 35 was supposed to be on a carb controlled diet. During an interview on 10/24/24 at 2:01 p.m., the Administrator indicated the discharge orders from the hospital had been for a carb controlled diet but the diet had been put in wrong at the facility when the resident admitted . On 10/25/24 at 12:09 p.m., the Administrator provided the facility's policy,Diet Orders undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Guideline: Each resident will have a diet order prescribed by the physician . Procedure: 3. Nursing confirms the the diet order is written utilizing standard terminology of the house diets before it is confirmed in the health record . 3.1-20(a)

Based on observation, interview, and record review, the facility failed to label medications with an open and expiration dates for 1 of 1 medication rooms observed. (Medication Room, Resident 14) Findings include: On 10/24/24 at 11:00 a.m., the refrigerator in the medication room was observed to have a vial of tuberculin PPD (purified protein derivative, a solution to aid in diagnosis of a tuberculosis infection) without an open or expiration date. An Ozempic injector pen (an injectable medication used to treat type 2 diabetes) for Resident 14, was observed without an open date or an expiration date. The Director of Nursing (DON) could not find an open date or an expiration date on either medication. The DON indicated every medication that was opened should have an open date and an expiration date on the vial or the pen. The DON was unsure when to discard medications after they were opened. On 10/24/24 at 11:25 a.m., the Administrator provided the facility's policy on Medication Storage, dated 7/2/19, and indicated it was a current policy being used by the facility. A review of the policy indicated .5. Once any medication . is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container . 3.1-25(j)

Based on interview and record review, the facility failed to ensure the notification of the bed hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization . (Resident 33) Findings include: Residents 33's clinical record was reviewed on 10/22/24 at 2:02 p.m. The diagnoses included, but were not limited to, dementia and fracture of the left femur. Resident 33's progress notes indicated the resident was sent to the hospital on 9/30/24. The clinical record lacked documentation the written notification which specified the facility's bed hold policy was provided to the resident or the resident representative. During an interview on 10/24/24 at 2:45 p.m., the Administrator indicated the forms were sent in writing to the resident representative but was not documented. On 10/25/24 at 12:09 p.m., the Administrator provided the facility's policy,Bed Hold and Return to Facility, dated 11/28/12, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Guidelines: . The facility bed hold policy will be given to the resident and/or resident representative as follows . At the time of a transfer from the facility . In cases of emergency transfer, notice [at time of transfer] means that the family or representative are provided with written notification within 24 hours of the transfer . 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a 2 of 2 residents reviewed for nutrition. Weight loss and IV (intravenous) nutrition were coded inaccurately. (Resident 7, Resident 31) Findings include: 1. Resident 7's clinical record was reviewed on 10/25/24 at 10:00 a.m. The diagnosis included, but was not limited to, Alzheimer's Disease. A review of the Weights and Vitals Summary for Resident 7 indicated the following: -On 6/24/24, the resident weighed 116 pounds. -On 7/8/24, the resident weighed 110 pounds. -On 8/5/24, the resident weighed 109 pounds. -On 9/4/24, the resident weighed 105 pounds. -On 10/11/24, the resident weighed 101 pounds. This was an assessed 12.93% severe weight loss in 5 months. Resident 7's Annual MDS assessment, dated 10/7/24, indicated the resident weighed 134 and weight loss had not been assessed during the look back period. During an interview on 10/25/24 at 10:15 a.m., the Assistant Director of Nursing indicated the Annual MDS assessment, dated 10/7/24, for Resident 7 had been coded incorrectly for the resident's weight loss and weight during the look back period. 50647 2. On 10/22/24 at 1:43 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, dysphagia (swallowing difficulties), and respiratory failure. The Admission MDS assessment, dated 9/13/24, indicated the resident received Parenteral/IV (a method of providing nutrition directly into the bloodstream through a vein) and tube feedings (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) while a resident. The Physician's orders, dated 9/10/24, indicated the resident was receiving enteral feeding (tube feeding). During an interview with the DON on 10/25/24 at 9:40 a.m., the DON indicated the resident only had tube feedings and had not had IV feedings since admitted . During an interview with the Assistant Director of Nursing (ADON)/MDS Coordinator on 10/25/24 at 9:48 a.m., indicated that the resident never had an IV for feedings and the MDS assessment was marked incorrectly on admission. During an interview with the Administrator on 10/25/24 at 10:05 a.m., she indicated they did not have a MDS assessment coding policy. They followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment. 3.1-31(d)

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of resident property though the diversion of a resident's controlled substance for staff use for 1 of 3 residents reviewed for misappropriation of property. (Resident B) Finding includes: During an interview on 4/5/24 at 9:30 a.m., the Minimum Data Set (MDS) Coordinator indicated on the morning of 3/2/24 she received a call from Licensed Practical Nurse (LPN) 1 who reported 2 cards of oxycodone (a narcotic medication) were missing for Resident B. She contacted all nurses who had worked that week and had them submit urine drug screens. On 3/4/24, all staff, with the exception of LPN 2 met and submitted urine drug screens. On 3/13/24, LPN 2 submitted a urine drug screen which tested positive for oxycodone, oxymorphone, and oxycodone/oxymorphone. On 4/5/24 at 10:30 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, sarcopenia (age-related progressive loss of muscle mass and strength), hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left dominant side, pain disorder with related psychological factors, muscle weakness, lack of coordination, difficulty walking, type 2 diabetes mellitus with diabetic neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and major depressive disorder. A 3/21/24 Quarterly MDS assessment indicated the resident was prescribed a scheduled pain medication regimen, his pain frequency was occasional, and the pain intensity was rated a 6 out of 10, with 10 being the worst pain experienced. A 10/4/23 physician's order indicated Resident B was prescribed oxycodone-acetaminophen 10-325 milligrams, every 4 hours related to pain disorder with related psychological factors. A 2/26/24 pharmacy invoice indicated the resident had 174 tablets of oxycodone delivered at 3:41 p.m. On 4/5/24 at 10:15 a.m., the Administrator provided an undated Timeline for [Resident B's] oxycodone 10/325. The timeline indicated the following: - 174 tables were received on 2/26/24 by LPN 5 and placed in the cart. Two cards (60 pills) were assigned one sheet of paper. In total, 6 cards of medication and 3 sheets of paper were placed in the medication cart. - On 2/26/24 at 6:00 p.m., cards and papers were counted by two staff. - On 2/27/24 at 6:00 a.m., cards and papers were counted by two staff. - On 2/27/24 at 6:00 p.m., cards and papers were counted by two staff. - On 2/28/24 at 6:00 a.m., cards and papers were counted by two staff. - On 2/28/24 at 6:00 p.m., cards and papers were counted by two staff. - On 2/29/24 at 6:00 a.m., cards and papers were counted by two staff. - On 2/29/24 at 6:00 p.m., cards and papers were counted by two staff. - On 3/1/24 at 6:00 a.m., cards and papers were not counted by two staff. - On 3/1/24 at 6:00 p.m., cards and papers were not counted by two staff. - On 3/2/24 at 6:00 a.m., cards and papers were counted and discovered missing by staff. A 3/13/24 specimen result certificate for LPN 2 indicated her urine tested positive for oxycodone, oxymorphone, and oxycodone/oxymorphone. The lab's final result disposition indicated the test was positive and they were unable to contact the donor. The test was verified on 3/20/24 at 8:39 a.m. A 3/1/24 electronic correspondence sent to the facility from the agency LPN 2 worked indicated she had violated their code of conduct policy high offense for a positive drug test resulting in termination of employment. LPN 3 was not able to be reach via telephone. A review of his written statement, dated 3/4/24 at 8:05 a.m., indicated he did not perform an oncoming narcotic count on 3/1/24. RN 1 was not able to be reached via telephone. A review of his written statement, dated 3/2/24, indicated on 3/1/24 at 6:00 p.m., he was unable to validated the number of the cards because it was not updated for days in the overflow box. On the morning of 3/2/24, during shift change, he tried to reconcile the number of cards and sheets with the day nurse. It was during this reconciliation when they discovered the missing oxycodone. During an interview on 4/5/24 at 9:40 a.m., the Director of Nursing indicated the on-coming and off-going shift nurses were to do a narcotic medication count together to ensure the medication count was accurate. During an interview on 4/5/24 at 11:25 a.m., Qualified Medication Aide (QMA) 1 indicated she did not do a narcotic count with LPN 2 on the front medication cart, only the back cart, which she was scheduled to work. She indicated LPN 3 was scheduled to work the front cart and he was running a little late. She assumed he would do a narcotic count with LPN 2 because that was his cart. During an interview on 4/5/24 at 12:26 p.m., LPN 4 indicated she noticed a discrepancy with the resident's numbered medication cards and narcotic sheets. The cards were labeled 1 through 6 and cards 3 and 4 were missing. She further indicated she knew the resident would have had a new oxycodone shipment delivered because she had to pull the medication from the emergency drug kit (EDK) the week prior. She was unable to locate cards 3 and 4. On 4/5/24 at 9:59 a.m., the Director of Nursing provided the facility policy, Narcotic/Controlled Substances- Counting, revised on 11/26/17, and indicated it was the policy currently being use. A review of the policy indicated, . count controlled substances with a partner and to verify the accuracy of the log sheets . 1. Always participate in the counting of the controlled substances at the beginning and ending of your shift . 3. Have partner assist in the count . 7. Count the remaining doses . 13. Listen while partner verifies the count . 19. Return keys to appropriate person . On 4/5/24 at 11:47 a.m., the Director of Nursing provided the facility policy, Residents' Rights, undated, and indicated it was the policy currently being use. A review of the policy indicated, . HH. The facility shall exercise reasonable care for the protection of residents' property from loss and theft . This deficient practice was corrected on 3/7/24 after the facility implemented a systemic plan that included the following actions: In servicing staff on counting narcotic medications and implementing ongoing monitoring of narcotic medication counting. This citation relates to Complaint IN00429694. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored and served in a sanitary manner for 3 of 3 kitchen observations. The hand washing station did not have hot water, the air conditioning unit was dirty, items in the refrigerator and freezer were unlabeled, and the chemical strips used for the 3 compartment sink were expired. This had the potential to impact 30 of 30 residents residing in the facility. Findings include: 1. During an initial tour of the facility kitchen on [DATE] at 10:15 a.m., the following was observed: - The hot water in the handwashing sink would not get hot. The Dietary Manager (DM) indicated at that time to use the 3 compartment sink because the water from that pipe would get hot. - The tubing around the wall air conditioning (A/C) unit was dirty with dust and debris and the vent slabs were observed to be dirty with a dark black substance. - The freezer was observed to have 5 packages of frozen meats that were unlabeled. The DM indicated at that time they were hamburger. - The refrigerator was observed to have a pitcher of a red liquid, a gallon of tea that that was almost gone and a gallon of milk that was almost gone with no open or use by date. The DM indicated at that time the red liquid had just been made this morning and the tea and milk would be gone by noon today. 2. During a follow up visit to the kitchen on [DATE] at 11:30 a.m., the following was observed: - The hot water in the handwashing sink would not get hot. - The tubing around the wall air conditioning unit was dirty with dust and debris and the vent slabs were observed to be dirty with a dark black substance. - The freezer was observed to have 5 packages of frozen meats that were unlabeled. - The refrigerator was observed to have 2 containers of cottage cheese bowls undated. - The chemical strips used to test the 3 compartment sink had expired on [DATE]. During an interview on [DATE] at 11:31 a.m., the DM indicated the A/C unit was dirty, the hand washing sink would not produce hot water, the test strips were expired, the cottage cheese bowls were being used today and the hamburger in the freezer was unlabeled. 3. During a follow up visit to the kitchen on [DATE] at 3:29 p.m., the following was observed: - The handwashing sink hot water measured with a thermometer to be 70.5 degrees. Cook 1 indicated at that time the hot water had never been hot in the sink. They had reported it but it never had been fixed. During an interview on [DATE] at 3:45 p.m., the Administrator indicated they have had the main water line replaced and they were still working on the hot water issues in the facility. On [DATE] at 6:06 p.m., the Administrator provided the facility policy titled, Sanitization with a revised date of [DATE], and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy Interpretation and Implementation . 2. All . equipment shall be kept clean . On [DATE] at 6:06 p.m., the Administrator provided the facility policy titled, Food Receiving and Storage with a revised date of [DATE], and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated [use by date] . A review of the above policies did not indicated having hot water in the hand washing sink and the expired chemical test strips. On [DATE] at 1:00 p.m., a review of the Indiana State Department of Health Retail Food Establishment Sanitation Requirements manual, effective date [DATE] indicated, .410 IAC ,d+[DATE] . Handwashing: .Sec. 128 a. Food employees shall . clean their hands and exposed portions of their arms . at a hand washing sink . in water having a temperature of at least one hundred (100) degrees Fahrenheit and thoroughly rinsing with clean water . Food Labels: Sec. 146. a. Food packaged in a retail food establishment shall be labeled as specified in law . b. Label information shall include the following: 1. The common name of the food or, absent a common name, an adequately descriptive identity statement . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for Quarter 3 (April 1 to June 30) of fiscal year 2023. Findings include: On 11/13/23 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN Hours for 4/2/23, 4/9/23, 5/7/23, 5/21/23, 6/4/23, and 6/18/23. The report further indicated the facility failed to have Licensed Nursing Coverage 24 hours per day on 4/2/23, 4/4/23, 4/8/23, 4/14/23, 4/15/23, 4/16/23, 4/21/23, 4/22/23, 4/30/23, 5/2/23, 5/6/23, 5/7/23, 5/8/23, 5/10/23, 5/11/23, 5/12/23, 5/14/23, 5/15/23, 5/16/23, 5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, 6/3/23, 6/4/23, 6/5/23, 6/8/23, 6/10/23, 6/11/23, 6/18/23, 6/19/23, 6/22/23, 6/23/23, 6/24/23, 6/25/23, 6/26/23. Lastly, the facility received a 1 star staffing rating during the third quarter. On 11/15/23 at 11:46 a.m., a review of the third quarter staffing schedules indicated the facility had no RN hours on 4/2/23, 4/9/23, 5/7/23, and 6/24/23. An additional review of the last thirty days of schedules indicated there were no RN hours for 10/21/23 and 10/22/23. During an interview on 11/16/23 at 12:00 p.m. the Administrator (ADM) indicated staff was late updating the schedule into a program accessible by computer and thought that may be why the PBJ report triggered so many days. She was unsure, but thought the staff included agency staff into the PBJ numbers. During an interview on 11/16/23 at 4:38 p.m., the ADM indicated during the third quarter of 2023, corporate staff was responsible for inputting the PBJ data to CMS. They had performed a schedule audit and are trying to hire a RN. On 11/16/23 at 6:07 p.m., the ADM provided the facility policy, Reporting Direct-Care Staffing Information (Payroll-Based Journal), revised July, 2006, and indicated it was the policy currently being used. A review of the policy indicated, . 2. Direct-care staffing information will include those hired through an agency, and contract employees . 9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter . Fiscal Quarter 3 . Date Range April 1 - June 30 . Submission Deadline August 14 .

Based on interview and record review, the facility failed use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 6 of 120 days reviewed. Findings include: On 11/13/23 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN Hours for 4/2/23, 4/9/23, 5/7/23, 5/21/23, 6/4/23, and 6/18/23. On 11/15/23 at 11:46 a.m., the third quarter staffing schedules (4/1/23-6/30/23) were reviewed. The staffing schedules indicated the facility had no RN scheduled on 4/2/23, 4/9/23, 5/7/23, and 6/4/23. A further review of the last thirty days of staffing schedules indicated there were no RN scheduled for 10/21/23 and 10/22/23. During an interview on 11/16/23 at 12:00 p.m. the ADM indicated they were late updating the schedule into a program accessible by computer and thought that may be why the PBJ report triggered so many days. She further indicated the facility did not have any RN coverage on 4/2/23, 4/9/23, 5/7/23, 6/4/23, 10/21/21 and 10/22/23. During an interview on 11/16/23 at 4:38 p.m. the ADM indicated during the third quarter of 2023 (4/1/23-6/30/23), corporate staff was responsible for inputting data into the PBJ. They had performed a schedule audit and were trying to hire a RN. On 11/16/23 at 6:07 p.m., the Administrator provided the facility policy, Departmental Supervision, revised April, 2006, and indicated it was the policy currently being used. A review of the policy indicated, . 1. A Registered or Licensed Practical/Vocational Nurse . is on duty twenty-four hours per day, seven days per week . An RN shall be available in the facility, daily, for 8 consecutive hours each day . 3.1-17(b)(3)

Based on observation, interview and record review, the facility failed to ensure residents were provided with fresh water on a routine basis for 5 out of 5 residents reviewed for hydration. (Resident 133, Resident 25, Resident 22, Resident 23, Resident 29) Findings include: 1. During an interview on 11/13/23 at 11:33 a.m., Resident 133 indicated she was not getting enough to drink because the facility did not pass water. No water was observed to be at the residents bedside during that time. During an observation on 11/14/23 at 1:59 p.m., Resident 133 was observed to be lying in her bed asleep. There was a gray pitcher with a straw observed on the back dresser that was undated and 3/4 full of warm water with no ice. During an interview on 11/14/23 at 3:16 p.m., Resident 133 indicated she had not known there was a gray water pitcher on the dresser next to the bed and she would have only noticed it if it had been on the bedside table. During an observation on 11/15/23 at 9:45 a.m., Resident 133 was out of the room attending PT (physical therapy). There was a gray pitcher with a straw observed on the bedside table that was undated and 1/4 full of warm water with no ice. During an observation on 11/15/23 at 11:38 a.m., Resident 133 was out sitting in her room in a wheelchair. There was a gray pitcher with a straw observed on the bedside table that was undated and full of ice and water. The resident indicated at that time that today was the first day she had seen the facility pass water. During an observation on 11/16/23 at 9:40 a.m., Resident 133 was out of the room sitting at the nurses station in her wheelchair. There was a gray pitcher with a straw observed on the bedside table that was undated and 3/4 full of warm water with no ice. Resident 133's clinical record was reviewed on 11/16/23 at 11:38 a.m. The diagnoses included, but were not limited to, type II diabetes mellitus and hypertension. The Admission Minimum Data Set (MDS) assessment, dated 11/14/23, was still in progress and had not assessed Resident 133's cognitively status at that time. 2. During an interview on 11/13/23 at 12:27 p.m., Resident 25 indicated she was not getting enough to drink because the facility did not pass water. No water was observed to be at the residents bedside during that time. During an observation on 11/14/23 at 1:56 p.m., Resident 25 was observed to be out of her room. No water was observed to be at the bedside. During an observation on 11/16/23 at 9:44 a.m., Resident 25 was observed to be asleep in bed. No water was observed to be at the bedside. During an observation on 11/15/23 at 11:39 a.m., Resident 25 was observed to be out of her room. No water was observed to be at the bedside. During an observation on 11/15/23 at 2:51 p.m., Resident 25 was observed to be out of her room. There was a gray pitcher with a straw observed on the bedside table that was undated and 3/4 full of warm water with no ice. During an observation on 11/16/23 at 10:39 a.m., Resident 25 was observed to be lying in bed asleep. A small clear cup of water 3/4 full used for med pass was observed at bedside however, no water pitcher with ice was observed. Resident 25's clinical record was reviewed on 11/16/23 at 11:52 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 8/21/23, indicated Resident 25 was cognitively intact. 38312 3. On 11/13/23 at 3:07 p.m., Resident 22 indicated he only gets ice water if he asked for it. At that time, Resident 22 had a clear medication glass at beside which was almost empty. On 11/14/23 at 3:04 p.m., Resident 22 was observed to have a clear medication cup on his bedside table which was half full. On 11/15/23 at 9:18 a.m., Resident 22 was observed to have a clear medication glass on his bedside table which was one quarter full. On 11/16/23 at 11:06 a.m., Resident 22's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and muscle weakness. The dehydration care plan, dated 5/8/23, indicated the staff were to encourage good fluid intake with dietary parameters. 4. During an observation on 11/13/23 at 2:56 p.m., Resident 23 was not observed to have a water pitcher at bedside. During an observation on 11/15/23 at 9:49 a.m., Resident 23 was observed to have a clear water glass at bedside which was one quarter full. A water pitcher was not observed to be at bedside. On 11/16/23 at 9:45 a.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, cognitive impairment and muscle weakness. The dehydration care plan, dated 10/25/23, indicated the staff were to encourage good fluid intake with dietary parameters. 5. During an observation on 11/13/23 at 11:31 a.m., Resident 29 indicated he would only get ice water if he asked for it. At that time, Resident 29 did not have a water pitcher at bedside. During an observation on 11/14/23 at 9:11 a.m., Resident 29 was observed to have a clear medication cup at bedside, but no water pitcher was observed to be at bedside. On 11/16/23 at 12:20 p.m., Resident 29's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and muscle weakness. The dehydration care plan, dated 4/27/23, indicated the staff were to encourage good fluid intake with dietary parameters. During the Resident Council Meeting on 11/14/23 at 2:16 p.m., the Resident Council President indicated they only get fresh ice or water if they ask for it. During an interview on 11/16/23 at 3:10 p.m., Certified Nursing Assistant (CNA) 1 indicated some days they do not have enough time to complete all their required task. Some of the tasks they can't complete was ice pass. The ice pass was at the bottom of the list. On 11/16/23 at 6:06 p.m., the Administrator provided the facility's policy, Resident Rights, revised date of 12/2016, and indicated it was the policy being used by the facility. A review of the policy indicated, .Federal and state laws guarantee certain basic rights to all residents .a. a dignified existence . 3.1-46(b)(2)

Based on observation and interview, the facility failed to ensure a clean and sanitary environment for 6 of 11 resident rooms and 4 of 4 bathrooms observed. Water temperatures in resident room sink faucets were not hot, floor tiles were not in place and clean, and toilet bases were not clean. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Northeast Bathroom, Northwest Bathroom, Southeast Bathroom, Southwest Bathroom) Findings include: 1. On the following dates and times, the hot water temperature for each resident room sink faucet was measured for a period of 3 minutes, with the temperature results documented: - On 11/16/23 from 11:00 A.M. to 11:03 A.M., room [ROOM NUMBER]'s hot water temperature was 77.1 degrees Fahrenheit. - On 11/16/23 from 11:06 A.M. to 11:09 A.M., room [ROOM NUMBER]'s hot water temperature was 64.8 degrees Fahrenheit. - On 11/16/23 from 11:12 A.M. to 11:15 A.M., room [ROOM NUMBER]'s hot water temperature was 76.2 degrees Fahrenheit. 2. On 11/15/23 between 11:15 A.M. and 11:45 A.M., the following resident rooms were observed to have floor covering of vinyl planks which were loose, missing, and with black and brown substances in the spaces between the planks: room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. 3. On 11/15/23 at 11:50 A.M., the southeast resident bathroom was observed to have a toilet with a dark brown colored substance around the base as well as brown staining along the wall to floor joints. 4. On 11/15/23 at 11:53 A.M., the northeast resident bathroom was observed to have a toilet with a dark brown colored substance around the base. 5. On 11/15/23 at 11:56 A.M., the southwest resident bathroom was observed to have a toilet with a dark brown colored substance around the base. 6. On 11/15/23 at 11:58 A.M., the northwest resident bathroom was observed to have a toilet with a dark brown colored substance around the base. During an interview on 11/16/23 at 3:00 P.M., the Maintenance Director indicated the hot water boiler which went to several resident rooms was in need of repair in order to heat the water to the proper temperature, the floor tiles were not staying in place and contained stains under them and between the seams, and the toilet bases of the restrooms were in need of cleaning and sealing, 3.1-19(f)

Based on interview and record review, the facility failed to ensure residents had full access to their facility managed personal funds account during the weekend hours for 1 of 16 residents reviewed for personal funds. (Resident 5) Findings include: During an interview on 11/13/23 at 3:49 p.m., Resident 5 indicated he was unable to get the full amount of money from his personal funds account on the weekends. The facility limited him on how much he could have. Resident 5's clinical record was reviewed on 11/15/23 at 10:00 a.m. The diagnosis included, but was not limited to, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment, dated 9/4/23, indicated Resident 5 was cognitively intact. During an interview on 11/16/23 at 4:08 p.m., the Business Office Manager (BOM) indicated the residents would line up outside her office on Friday because they were only allowed to get between $5.00 and $10.00 out of their personal funds account on the weekend. She only kept $40.00 on hand. On 11/16/23 at 4:00 p.m., the BOM provided the facility's policy, Resident Facility Trust Fund Policy and Procedure undated, and indicated it was the one currently being used by the facility. A review of the policy indicated, . Normal Process of Handling Resident Trust . 3. The resident is able to request and receive funds from this account at any time . 4. The resident can withdrawal cash to do what they choose with . 3.1-6

Based on observation, record review, and interview, the facility failed to ensure appropriate treatment and services to prevent a urinary tract infection for 1 of 2 residents reviewed for urinary catheter care, in that the facility failed to implement their urinary catheter care policy(s). (Resident #B) Findings include: Resident #B's clinical record was review on February 26, 2013 at 9:30 a.m. Resident #B's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." Continued review of the clinical records indicated on December 17, 2012; Resident #B was transferred to a local acute care hospital emergency room for evaluation and treatment, due to a change in condition. The acute care hospital Discharge Summary dated December 31, 2012; indicated, "Admit 12/17/2012 ... Discharge Diagnoses: [REDACTED]. ... Hospital Course: The patient is a _____ (age)-year-old bed-bound _____(gender) who presented with abdominal and pelvic pain. In the Emergency Department, _____ (gender) was found to be in acute renal retention and a Foley catheter was replaced. _____ (gender) had a catheter in at the nursing home, apparently had occluded. One liter of urine flowed, and the patient's pain improved dramatically. Urinary tract infection was identified, it is related to the prior catheter, and was present on admission. Unfortunately it was extended spectrum resistant E coli, requiring IV antibiotics. ... a PICC (peripherally inserted central catheter (venous access via vena cava/principal vein) ) catheter is being placed. ..." The summary indicated Resident #B remained at the hospital until December 31, 2012 (14 days). The acute care hospital's Social Worker was interviewed on February 26, 2013 at 8:55 a.m. During the interview the Social Worker indicated having received a report from the emergency department in regard to Resident #B's indwelling catheter appearing to have been old, not recently changed, and when questioned Resident #B indicated; " 'not being able to recall the catheter being changed at all.' " Continued review of Resident #B's clinical records, the records lacked documentation to indicate the indwelling catheter had been changed from October 23, 2012 (date initiated) to December 17, 2012 (date of hospital admission). Interview, on February 26, 2013 at 10:55 a.m.; the Director of Nursing indicated indwelling catheter care documentation is recorded on the Treatment Administration Record(s) (TAR). Documentation was not recorded on the TAR's, Resident B's indwelling catheter had been changed. A facility policy (non-dated) titled, "Catheter Care, Urinary" provided by the Director of Nursing on February 26, 2013 at 11:30 a.m.; indicated, "Purpose: The purpose of this procedure is to prevent infection of resident's urinary tract. 1. Review the resident's care plan to assess for any special needs of the resident. Depending on the resident's assessment and needs, the catheter may require changing every 30 days or more often as needed. ..." Resident #B was observed on February 26, 2013 at approximately 9:05 a.m; during initial tour. The Director of Nursing was present. Resident #B was positioned in bed on a low air loss mattress. The mattress had bumpers which extended from the top to the bottom, on the left and right sides. Resident #B's catheter's drainage tube was positioned over the top of the left bumper (above bladder level) down to the drainage bag. When the Director of Nursing was questioned, she indicated that is how nursing staff position the drainage tube on a daily basis. A quarterly review Minimum Data Set Assessment (evaluation of physical, mental, and psychosocial health stauts) dated January 23, 2013; indicated Resident #B's cognitive status was coded at 14 (cognitively intact). Resident #B was dependent on nursing staff for activities of daily living. The Urinary Catheter Care policy provided by the Director of Nursing on February 26, 2013 at 11:30 a.m.; indicated, "Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: ... 4. The urinary drainage bag must be held or positioned lower that the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder." On February 26, 2013 at 11:35 a.m.; the Director of Nursing and Administrator indicated the position of Resident #B's drainage tubing was above bladder level and provided the potential of back flow of urine into the bladder. The drainage tubing and bag were repositioned to the foot of the bed, below the level of Resident #B's bladder. This Federal tag relates to Complaint IN 987. 3.1-41(a)(2)

Based on interview, record review and observation, the facility failed to ensure policies and procedures were implemented to protect residents from staff members who created an environment of fear, for 12 of 13 residents reviewed for abuse. This had the potential to affect all 30 of 30 residents residing within the facility. Residents A, B, C, D, F, G, H, I, J, K, L, and M The Immediate Jeopardy began on 6/22/11 when a certified nursing assistant who had witnessed abuse at some point in the past, discussed it with a facility PTA (physical therapy assistant) who was providing her a ride home. The therapist then waited 2 days to tell the DON, with no documentation of the Administrator notified until the 3rd day. This resulted in a delayed investigation of the abuse, allowing the 2 staff members accused to continue to work on the floor with residents, as well as the health facility administrator failing to immediately suspend and investigate other allegations of abuse made by other staff members and failure of staff members to immediately report suspicions of abuse to the administrator. The Corporate Registered Nurse Consultant was notified of the Immediate Jeopardy at 1:00 P.M. on 8/17/11. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During interview with the Health Facility Administrator (HFA) on 8/17/11 at 9:15 A.M., she indicated she had reported an allegation of abuse to the state agency and provided the documentation she had faxed in as well as the investigation of the allegations. She indicated the two Certified Nursing Assistants, CNA # 1 and CNA #2, involved had been fired. She indicated she had no documentation of an inservice provided to staff members and had not obtained statements from all staff members who had worked with the two CNA's accused of abuse. She indicated she knew her staff and knew no one else was abusing anyone. She had talked with each staff member one on one about the policy for abuse, just had not written anything down. The HFA indicated when she had become aware of the situation, she had told the Director of Nursing (DON) to suspend CNA #1, but she found out a couple days later she had suspended CNA #2. The HFA indicated the DON had told her CNA #2 was also involved and that was the first the HFA knew about CNA#2's involvement. She indicated both CNA's were fired, CNA #1 for abuse and CNA #2 for witnessing it and not reporting it. The HFA indicated that was the company policy. The HFA indicated she could not remember when either of the CNA's were suspended but would try to find the dates. The incident reporting form, 5 day follow-up, dated as having been faxed, 6/29/11 at 12:47 P.M., indicated, "Reported by: HFA name, Resident B, Diagnoses: [REDACTED].#3 that CNA #1 was rude and used excessive force when moving resident on or around 6/23/11. Immediate Action Taken: Suspension of employee. Resident assessed and reinterpreted (sic). Initiated interviews for other alert and oriented residents. Preventative measures taken: ANE inservice schedule. Follow up-unable to substantiate. CNA #1 denies the allegations and with interviews could not substantiate the report. Employee has been terminated." Statements obtained from staff members included: "CNA #4, dated 6/29/11, Just to bring to attention that (CNA #2 name) in my personal opion (sic) is a little aggressive with personal care to residents. Maybe a fast turn her (sic) or a little bit hard to the other side.(sic) I personally would not have her take care of my grandma." Another note from CNA #4, dated 6/29/11, "Back when name of Resident D, was put on fluid restriction, she was wanting more to drank (sic) there was some confusion with whether or not she could have more. She, Resident D, asked for a glass of milk, the nurses said it was ok, CNA #1 then brought her 2 glasses of milk sat them on the table in front of her and said something to this effect if she wants to kill herself let her go ahead and drink all that she wants." During interview with CNA #4, on 8/18/11 at 2 p.m., she indicated CNA #1 had said within the hearing of Resident D to the effect of "go ahead and kill yourself its ok with me." CNA #4 indicated she did not report it at the time because a charge nurse heard it, too. CNA #4 could not remember what nurse for sure but thought it was DON #1. CNA #4 indicated she wrote the statements concerning CNA #1 and #2 on 6/29/11, because the HFA asked her to document anything she knew had occurred with those CNA's. A written statement from CNA #3, dated June 29, 2011, indicated, "I have witnessed CNA #2 and CNA #1 use excessive force on Resident B while tending to him. I have also been a witness to CNA #1 speaking very rudely to him. I have not witnessed either of them strike Resident B but there was an occurrence when I believe I heard CNA #1 slap Resident B in his room while my back was turned. I asked CNA #1 what happened immediately after. She was defensive and said he wouldn't let go of me. She never confirmed or denied slapping Resident B." A written statement from PTA #1, dated 7/18/11, indicated: "I received a call from CNA #3 on 7/18/11 at approximately 9 p.m. in regards to repeated phone calls from CNA #1 and CNA #2...CNA #3 told me that they had been harassing her and threatening to find her and harm her. She also informed me that CNA #2 had told her that she was going to call corporate and tell them that she had caught us having sex in the building to try and get us (me and CNA #3) fired, since we had according to CNA #2 gotten her and CNA #1 fired. So today I addressed this with HFA...." During interviews with PTA #1 on 8/17/11 at 9:30 A.M. and 2:30 P.M., he indicated CNA #3 had told him while riding in a car, that CNA #2 had punched a resident in the face. He indicated CNA #3 had changed it the CNA #1. PTA #1 indicated this was on a Friday night, he thought 6/22, because there was a going away party for a nurse he and other staff members attended. He indicated he told the DON on Sunday when he came to work as he did not work on Saturday. PTA #1 indicated he remembered talking to the HFA about this on he believed Monday, but did not write anything down and was not asked to write a statement. PTA #1 indicated he thought the HFA then had CNA #3 write something up the next time she was at work. The HFA provided employee counseling forms, on 8/17/11 at 10:00 A.M. The HFA further indicated at this time, the DON had not called her on 6/24/11 and told her about the PTA's report of allegations made by CNA #3 on 6/22/11. The employee counseling form, dated 6/29/11, for CNA #1 indicated "Suspension 2 or 3 days, upon investigation, reported by CNA that CNA #1 was very rude and used excessive force while moving resident on or around 6/23/11. CNA did not witness either CNA which was CNA #2, strike the resident but she believes she heard a slap to slap. CNA #1 did not deny slapping resident. State report filed 6/29/11." Another form, dated 7/1/11, for CNA #1, indicated "Discharge due to speaking with Residents and staff members. I have decided to Discharge CNA #1." An employee counseling form for CNA #2, dated 7/1/11, indicated "Discharge, excessive force when moving residents also not reporting to DON or HFA. CNA #2 used excessive force when moving resident. Also did not report team member who also used excessive force when moving a resident -this was a state reportable on 6/29/11. I gave a 3 day suspension for investigation of this matter." No date as to when the 3 day suspension was documented. The facility Office Manager, on 8/18/11 at 1:00 P.M., indicated CNA#1 worked 6/23, 25, 26, 29 with her last day to work as 6/30/11. CNA #2, worked 6/22, 26, with the last day to have worked as 6/27/11. The facility lacked evidence of having reported rough treatment of [REDACTED]. In an in interview with Resident B's spouse, on 8/17/11 at 12:30 P.M., she indicated she had not been informed of the alleged abuse to Resident B. She stated a CNA had let this slip to her one day. She stated the CNA had said "I can't believe you didn't move your husband." She stated when I asked her why she said that the CNA said "You didn't know about CNA # 1 slapping him?" She stated she then went to speak to the Administrator and the Director of Nursing and got two different stories of the incident. The clinical record for Resident B was reviewed on 8/17/11 at 9:30 A.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 7/6/11, indicated Resident B had short and long term memory problems and severely impaired decision making. Resident B required extensive assistance of one with bed mobility, and extensive assistance of two with transfers and toilet use. 2. During interview with CNA #9 on 8/17/11 at 10:15 A.M., she indicated she was glad the HFA had fired CNA #1 and #2 as they were mean and did not follow protocol for lift use. CNA #9 indicated this was normal for them, but the previous DON had made excuses for them. CNA #9 indicated she had expressed concerns to the previous DON and the previous HFA. She indicated they had simply cut her time on the schedule to almost nothing afterwards. CNA #9 indicated CNA #3 had told her a couple of months ago that CNA #2 and CNA #1 had smacked Resident B. CNA #9 indicated she had not been asked for any statements concerning abuse she had witnessed. CNA #9 indicated she had reported to her charge nurse and the HFA that morning (8/17), what she thought was abuse that she observed the day before (8/16). CNA #9 indicated on 8/16/11, her and CNA #6 heard Resident 'I' screaming from the shower room. CNA #9 indicated CNA #5 had been giving the resident a shower, but had left her alone in the shower room without a call bell. CNA #9 indicated her and CNA #6 went to see what was wrong and had dressed Resident 'I' and transferred her to her chair. CNA #9 indicated CNA #5, upon returning to the shower room, had asked them what they were doing. When they (CNA #9 and #6) told CNA #5 the resident had been screaming and they went to see what was wrong, CNA #5 went into the hall and told the resident 'Don't you never ever start screaming like that again.' " CNA #9 indicated she told her charge nurse, LPN #1 this morning, 8/17/11, she indicated LPN #1 told her to go tell the HFA when she (the Administrator) got to the facility, which she had done and provided the HFA a write up on it. CNA #9 further indicated Resident D, Resident C and Resident F, all had complaints concerning treatment by CNA #5. She indicated they should be spoken to. CNA #9 indicated Resident F was out of the facility at this time. CNA #9 indicated Resident F was very concerned with conserving water and had asked CNA #5 to turn her water off and CNA #5 had became upset. Resident F then asked CNA #9 and #10 to provide her care as CNA #5 had gave her a dirty look and was hateful and she did not want her providing care again. Resident F's clinical record was reviewed on 8/17/11 at 11:00 A.M. The MDS (Minimum Data Set) assessment, dated 7/28/11, indicated Resident F had no problems with cognition. Resident F required limited assistance of one with bed mobility, extensive assistance of one with bathing and was dependent with toilet use. CNA #9 further indicated Resident D had told her, some time back, that CNA #5 was getting her up with a stand lift, and her foot fell off. When Resident D complained, CNA #5 accused her of whining and told Resident D not to ever ask her for anything again. CNA #9 indicated Resident D does not want CNA #5 providing care for her. She indicated this is not written anywhere, but just common knowledge among the CNA's. On 8/17/11 at 9:30 A.M., CNA # 5 was observed in a resident room providing care. 3. During an interview with Resident D on 8/17/11 at approximately 10:30 A.M., she indicated CNA #5 had told her she did not like her, will not come into her room or do anything for her. She indicated if she asked for anything, CNA #5 would turn her head or just say,"No." Resident D indicated she had asked for milk, and CNA #5 looked at her and said "No." Resident D indicated she had told the HFA about this and the HFA brought CNA #5 into the room, and CNA #5 simply denied ever doing anything. Resident D's clinical record was reviewed on 8/17/11 at 1:00 P.M. The MDS (Minimum Data Set) assessment of 7/13/11, indicated Resident D had no problems with cognition. Resident D required extensive assistance of two with bed mobility, and dependent on two staff with transfers and toilet use. In an interview with Resident C, on 8/17/11 at 10:25 A.M., he was observed to be in bed with his cat beside him. He indicated CNA # 5 was very rough in handling him. He indicated CNA # 5 was very rude and talked down to him. He also indicated CNA # 6 had a chip on her shoulder and was mean during care. He further indicated he had reported this to the Administrator, but she didn't do anything. He indicated after reporting this to the Administrator, she had told him his pet cat that had lived with him at the facility for 5 years had to go. He indicated he had banned CNA # 5 from providing any care for him. The clinical record for Resident C was reviewed on 8/17/11 at 1:20 P.M. The record indicated Resident C had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 6/15/11, indicated Resident C had no impairment in cognition. Resident C required extensive assistance of two with bed mobility and toilet use. The Nurse's Notes, dated 8/12/11 at 11:00 P.M., indicated "Asked me if I knew about his cat, was very upset about having to lose her." In an interview with Resident G, on 8/17/11 at 11:00 A.M., she indicated CNA # 5 was always talking down to me. She stated CNA # 5 would always make comments about her clothing and how she combed her hair. She stated "I didn't want her to talk to me that way. I want to do as much as I can for myself." She also indicated she was a minister, and she stated that RN # 1 had called her the devil. She was very upset and misty eyed and asked "Why would she do something like that? I am not a bad person." The MDS (Minimum Data Set) assessment, dated 7/13/11, indicated Resident G had moderately impaired cognition. Resident G was independent with bed mobility, transfers, and ambulation. Resident G required limited assistance of one with toilet use and personal hygiene. 4. During interview with LPN #1, on 8/17/11 at 11:15 A.M., she indicated she had told CNA #9 to tell the HFA when she got there that morning about the incident with CNA # 5 and Resident 'I'. She confirmed that CNA #5 was still working at that time. LPN #1 indicated she had only been working for 5 or 6 days and really did not know what the abuse protocol was. She indicated she just had not had a chance to attend general orientation. LPN #1's employee file was obtained from the Office Manager on 8/17/11 at 12:00 P.M. Documentation of training in the facility abuse protocol was lacking. The last 10 hired employees files were reviewed, on 8/17/11 at 1:00 P.M. Three of the 10 new employees had not been trained in the facility abuse protocol. 5. During interview with the HFA on 8/17/11 at 11:30 A.M., she indicated the only other allegation of abuse that she was aware of was on a form she had found in DON #1's office (old DON who now is on leave and will return as a floor nurse). The HFA went to the Business Office Manager's office and returned with the three notes at this time. The HFA administrator indicated she had just found it lately and was starting an investigation. There were 3 notes stapled together. Note 1 written by CNA #3, dated 7/7/11, indicated: "Resident H's family member made complaint that CNA #7 was very rough and rude with Resident H last night. CNA #7 allegedly came in to put her to bed and said something along the lines of what do you think you are doing? When Resident H asked who she was talking about, CNA #7 said you know what you did. Resident H says that CNA #7 was easy about undressing her and preparing her for bed. Resident H's family member is very upset and would like to speak to HFA as soon as possible. According to her this was an issue in the past." Note 2- dated 8/16/11 2:20 p.m., written by the HFA indicated "Spoke with CNA #7 about this note, told her I was accusing (sic) her of anything, all CNA's are going to keep their resident dry and safe. She was ok when she left office." Note 3- written by CNA #7, no date, indicated, "FYI- CNA on days, every morning before I go home, I check my people second of all me and CNA #8 had split up sections I never leave any of my residents wet or dirty so you need to talk with someone else or don't accuse me of leaving anyone soaked because I don't do that." (sic) The HFA indicated on 8/17/11 at 11:30 A.M., she had received no other reports of abuse. When asked about the allegations made by CNA #9 to her charge nurse and to the HFA that a.m., the HFA indicated she had not had time to investigate it yet. She further indicated she did not consider what was reported to her abuse. Nurse Consultant # 1 indicated it was considered abuse and CNA #5 would be sent home pending investigation. The HFA further indicated when she took over the facility it was a mess and she was trying to clean it up. She indicated she had not documented some of the things done because there was not time to look into things and document them. She indicated if she suspended all the staff accused of abuse there be no one to work. 6. During interview with Resident A's family on 8/17/11 at 12:00 P.M., they indicated while visiting at supper time, RN #1 was heard to be very hateful with Resident A. The family of Resident A further indicated yesterday (8/16) they had heard CNA #5, yell at Resident L to get back in the bed and she would get to her when she could. The family further indicated Resident M was a longtime friend of their family. Resident A's family had given a phone number for them to Resident M. This was taken away by the HFA and Resident M told she was not allowed to have the number or call the family. The family of Resident A indicated Resident M was scared to talk about it now and they had provided the number again and told her to keep it hid. 7. On 8/17/11 at 2:00 P.M., CNA # 10 provided a written statement, dated 8/17/11, which indicated "To whom it may concern, I (CNA # 10's name) saw CNA # 1 handle Resident (Resident J's name) in an unprofessional manner. She was rough when turning resident, didn't explain what she was doing to the resident, left B.M. (bowel movement) on bed and resident. We were doing walk thru at shift change. She also treated (Resident K's name) in room (number) the same way, never explained what was going on with them, turned him and changed him in a rough manner, again no peri care. I had to go behind her after she left and clean said residents. This is before I left in July 2011 (for vacation)..." During interview with CNA #10 at this same time, she indicated this had been reported to the HFA, and was before CNA #1 was suspended for other allegations of abuse. 8. The Health Facility Administrator provided, on 8/17/11 at 11:00 A.M., the last inservice provided on abuse to facility staff. The inservice was dated 3/25/11. CNA #2, PTA #1, CNA #6, CNA #9, CNA#7 and DON #1 had all signed as having attended. CNA#1 and CNA # 5 were not documented to have attended. The Abuse Prevention Program, policy and procedure, dated 8/2006, provided by the Health Facility Administrator, on 8/17/11 at 10:00 A.M., indicated, "Abuse Reporting...will have no tolerance with anyone not reporting and following the 7 steps of abuse, neglect and exploitation...when any allegation or confirmed abuse occurs, the appropriate state agencies need to be notified, and the DON and Administrator...need to check and see if this or any other thing has happened to any other resident...With any allegation or suspected or witnessed abuse every employee has a legal obligation to report the occurrence." The Abuse policy, dated 3/11, for Protocols for investigating, included: "Any employee who suspects an alleged violation shall notify the HFA/ DNS (Director of Nursing Services) ...immediately...the facility will investigate each allegation thoroughly and report the results to the HFA...the DNS shall notify the residents representative regarding the alleged incident. Inform the representative that an investigation has been initialed and appropriate actions will be taken...document this contact in the clinical record...if the suspect is an employee, they shall be placed on immediate suspension pending the results of the investigation...if the allegation involves physical abuse...a background check will be conducted to determine if any disqualifying offenses have occurred since the previous check...The investigation shall include interviews of employee, visitors or residents who may have knowledge of the alleged incident. Written documentation will be kept of each interview taken. The employee, resident or visitor may write their own report if desired...written statements form involved parties should be based on facts not opinions...training -orientation and ongoing in service training." The Immediate Jeopardy that began on 6/22/11 was removed on 8/19/11, when the facility demonstrated policies and procedures had been put in place to ensure staff were knowledgeable concerning the prevention of abuse, but noncompliance remained at the lowered scope and severity of widespread, at no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. This federal tag relates to Complaint IN 518. 3.1-28(a)

Based on interview, record review, and observation, the facility failed to ensure allegations of abuse voiced by residents and staff members were immediately reported to the administrator and thoroughly investigated, for 9 of 13 residents reviewed for abuse. This had the potential to affect all 30 of 30 residents residing within the facility. Residents B, C, D, F, H ,I ,J ,K, and L. The Immediate Jeopardy began on 6/22/11 when a certified nursing assistant who had witnessed abuse at some point in the past, discussed it with a facility PTA (physical therapy assistant) who was providing her a ride home. The therapist then waited 2 days to tell the DON, with no documentation of the administrator being notified until the 3rd day. This resulted in a delayed investigation of the abuse, allowing the 2 staff members accused to continue to work on the floor with residents, as well as the Health Facility Administrator failing to immediately suspend and investigate other allegations of abuse made by other staff members and failure of staff members to immediately report suspicions of abuse to the Administrator. The Corporate Registered Nurse Consultant was notified of the Immediate Jeopardy at 1:00 P.M. on 8/17/11. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During interview with the Health Facility Administrator (HFA) on 8/17/11 at 9:15 A.M., she indicated she had reported an allegation of abuse to the state agency and provided the documentation she had faxed in, as well as the investigation of the allegations. She indicated the two Certified Nursing Assistants, CNA #1 and CNA #2, involved had been fired. She indicated she had no documentation of an inservice provided to staff members and she had not obtained statements from all staff members who had worked with the two CNA's accused of abuse. She indicated she knew her staff and knew no one else was abusing anyone. She said she had talked with each staff member one on one about the policy for abuse, just had not written anything down. The HFA indicated when she had become aware of the situation, she had told the Director of Nursing (DON) to suspend CNA #1, but she found out a couple days later she had suspended CNA #2. The HFA indicated the DON had told her CNA #2 was also involved and that was the first the HFA knew about CNA#2's involvement. She indicated both CNA's were fired, CNA #1 for abuse and CNA #2 for witnessing it and not reporting it. The HFA indicated that was the company policy. The HFA indicated she could not remember when either of the CNA's were suspended but would try to find the dates. The incident reporting form, 5 day follow-up, dated as having been faxed, 6/29/11 at 12:47 P.M., indicated "Reported by: HFA name, Resident B, Diagnoses: [REDACTED].#3 that CNA #1 was rude and used excessive force when moving resident on or around 6/23/11. Immediate Action Taken: Suspension of employee. Resident assessed and reinterpreted (sic). Initiated interviews for other alert and oriented residents. Preventative measures taken: ANE inservice schedule. Follow up-unable to substantiate, CNA #1 denies the allegations and with interviews could not substantiate the report. Employee has been terminated." Statements obtained from staff members included: "CNA #4, dated 6/29/11, Just to bring to attention that (CNA #2 name) in my personal opion (sic) is a little aggressive with personal care to residents. Maybe a fast turn her (sic) or a little bit hard to the other side.(sic) I personally would not have her take care take of my grandma." Another note from CNA #4, dated 6/29/11, "Back when (name of Resident D), was put on fluid restriction, she was wanting more to drank (sic) there was some confusion with whether or not she could have more. She, Resident D, asked for a glass of milk, the nurses said it was ok. CNA #1 then brought her 2 glasses of milk sat them on the table in front of her and said something to this effect if she wants to kill herself let her go ahead and drink all that she wants." During interview with CNA #4, on 8/18/11 at 2 p.m., she indicated CNA #1 had said within the hearing of Resident D to the effect of "go ahead and kill yourself it's ok with me." CNA #4 indicated she did not report it at the time because a charge nurse heard it, too. CNA #4 could not remember what nurse for sure but thought it was DON #1. CNA #4 indicated she wrote the statements concerning CNA #1 and #2 on 6/29/11, because the HFA asked her to document anything she knew had occurred with those CNA's. A written statement, from CNA #3, dated June 29, 2011, indicated " I have witnessed CNA #2 and CNA #1 use excessive force on Resident B while tending to him. I have also been a witness to CNA #1 speaking very rudely to him. I have not witnessed either of them strike Resident B, but there was an occurrence when I believe I heard CNA #1 slap Resident B in his room while my back was turned. I asked CNA #1 what happened immediately after. She was defensive and said he wouldn't let go of me. She never confirmed or denied slapping Resident B." A written statement from PTA #1, dated 7/18/11, indicated : I received a call from CNA #3 on 7/18/11 at approximately 9 p.m. in regards to repeated phone calls from CNA #1 and CNA #2...CNA #3 told me that they had been harassing her and threatening to find her and harm her. She also informed me that CNA #2 had told her that she was going to call corporate and tell them that she had caught us having sex in the building to try and get us (me and CNA #3) fired, since we had according to CNA #2 gotten her and CNA #1 fired. So today I addressed this with HFA...." During interviews with PTA #1 on 8/17/11 at 9:30 A.M. and 2:30 P.M., he indicated CNA #3 had told him, while riding in a car, that CNA #2 had punched a resident in the face. He indicated CNA #3 had later changed it the CNA #1. PTA #1 indicated this was on a Friday night, he thought 6/22, because there was a going away party for a nurse he and other staff members attended. He indicated he told the DON on Sunday when he came to work as he did not work on Saturday. PTA #1 indicated he remembered talking to the HFA about this on he believed Monday, but did not write anything down and was not asked to write a statement. PTA #1 indicated he thought the HFA then had CNA #3 write something up the next time she was at work. The HFA provided employee counseling forms on 8/17/11 at 10:00 A.M. The HFA further indicated at this time, the DON had not called her on 6/24/11 and told her about the PTA's report of allegations made by CNA #3 on 6/22/11. The employee counseling form, dated 6/29/11, for CNA #1 indicated "Suspension 2 or 3 days, upon investigation, reported by CNA that CNA #1 was very rude and used excessive force while moving resident on or around 6/23/11. CNA did not witness either CNA which was CNA #2, strike the resident but she believes she heard a slap to slap. CNA #1 did not deny slapping resident. State report filed 6/29/11." Another form, dated 7/1/11, for CNA #1, indicated "Discharge due to speaking with Residents and staff members. I have decided to Discharge CNA #1." An employee counseling form for CNA #2, dated 7/1/11, indicated discharge, excessive force when moving residents, also not reporting to DON or HFA. CNA #2 used excessive force when moving resident. Also did not report team member who also used excessive force when moving a resident -this was a state reportable on 6/29/11. I gave a 3 day suspension for investigation of this matter." No date as to when the 3 day suspension was documented. The facility Office Manager on 8/18/11 at 1:00 P.M., indicated CNA#1 worked on 6/23, 25, 26, 29, with her last day to work as 6/30/11. CNA #2 worked 6/22, 26, with the last day to have worked as 6/27/11. The facility lacked evidence of having reported rough treatment of [REDACTED].. 2. During interview with CNA #9 on 8/17/11 at 10:15 A.M., she indicated she was glad the HFA had fired CNA #1 and #2 as they were mean and did not follow protocol for lift use. CNA #9 indicated this was normal for them, but the previous DON had made excuses for them. CNA #9 indicated she had expressed concerns to the previous DON and the previous HFA. She indicated they had simply cut her time on the schedule to almost nothing afterwards. CNA #9 indicated CNA #3 had told her a couple of months ago that CNA #2 and CNA #1 had smacked Resident B. CNA #9 indicated she had not been asked for any statements concerning abuse she had witnessed. CNA #9 indicated she had reported to her charge nurse and the HFA that morning (8/17), what she thought was abuse that she observed the day before (8/16). CNA #9 indicated on 8/16/11, her and CNA #6 heard Resident 'I' screaming from the shower room. CNA #9 indicated CNA #5 had been giving the resident a shower, but had left her alone in the shower room without a call bell. CNA #9 indicated her and CNA #6 went to see what was wrong and had dressed Resident 'I' and transferred her to her chair. CNA #9 indicated CNA #5, upon returning to the shower room, had asked them what they were doing. When they (CNA #9 and #6) told CNA #5 the resident had been screaming and they went to see what was wrong, CNA #5 went into the hall and told the resident 'Don't you never ever start screaming like that again.' " CNA #9 indicated she told her charge nurse, LPN #1 this morning, 8/17/11, she indicated LPN #1 told her to go tell the HFA when she got to the facility, which she had done and provided the HFA a write up on it. CNA #9 further indicated Resident D, Resident C and Resident F all had complaints concerning treatment by CNA #5. She indicated they should be spoken to. CNA #9 indicated Resident F was out of the facility at this time. CNA #9 indicated Resident F was very concerned with conserving water and had asked CNA #5 to turn her water off and CNA #5 had became upset. Resident F then asked CNA #9 and #10 to provide her care as CNA #5 had gave her a dirty look and was hateful and she did not want her providing care again. Resident F's clinical record was reviewed on 8/17/11 at 11:00 A.M. The MDS (Minimum Data Set) assessment, dated 7/28/11, indicated Resident F had no problems with cognition. Resident F required limited assistance of one with bed mobility, extensive assistance of one with bathing and was dependent with toilet use. CNA #9 further indicated Resident D had told her, some time back, that CNA #5 was getting her up with a stand lift, and her foot fell off. When Resident D complained, CNA #5 accused her of whining and told Resident D not to ever ask her for anything again. CNA #9 indicated Resident D does not want CNA #5 providing care for her. She indicated this is not written anywhere, but just common knowledge among the CNA's. On 8/17/11 at 9:30 A.M., CNA # 5 was observed in a resident room providing care. 3. During an interview with Resident D on 8/17/11 at approximately 10:30 A.M., she indicated CNA #5 had told her she did not like her, will not come into her room or do anything for her. She indicated if she asked for anything, CNA #5 would turn her head or just say,"No." Resident D indicated she had asked for milk, and CNA #5 looked at her and said "No." Resident D indicated she had told the HFA about this and the HFA brought CNA #5 into the room, and CNA #5 simply denied ever doing anything. Resident D's clinical record was reviewed on 8/17/11 at 1:00 P.M. The MDS (Minimum Data Set) assessment, 7/13/11, indicated Resident D had no problems with cognition. Resident D required extensive assistance of two with bed mobility, and dependent on two staff with transfers and toilet use. In an interview with Resident C, on 8/17/11 at 10:25 A.M., he was observed to be in bed with his cat beside him. He indicated CNA # 5 was very rough in handling him. He indicated CNA # 5 was very rude and talked down to him. He also indicated CNA # 6 had a chip on her shoulder and was mean during care. He further indicated he had reported this to the Administrator but she didn't do anything. He indicated after reporting this to the Administrator she had told him his pet cat that had lived with him at the facility for 5 years had to go. He indicated he had banned CNA # 5 from providing any care for him. The clinical record for Resident C was reviewed on 8/17/11 at 1:20 P.M. The record indicated Resident C had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/15/11, indicated Resident C had no impairment in cognition. Resident C required extensive assistance of two with bed mobility and toilet use. The Nurse's Notes, dated 8/12/11 at 11:00 P.M., indicated "Asked me if I knew about his cat, was very upset about having to lose her." 4. During interview with LPN #1, on 8/17/11 at 11:15 A.M., she indicated she had told CNA #9 to tell the HFA when she (the Administrator) got there that morning about the incident with CNA # 5 and Resident 'I'. She confirmed that CNA #5 was still working at that time. She indicated she had only been working for 5 or 6 days and really did not know what the abuse protocol was. She indicated she just had not had a chance to attend general orientation. LPN #1's employee file was obtained from the Office Manager on 8/17/11 at 12:00 P.M. Documentation of training in the facility abuse protocol was lacking. The last 10 hired employees files were reviewed, on 8/17/11 at 1:00 P.M. Three of the 10 new employees had not been trained in the facility abuse protocol. 5. During interview with the HFA on 8/17/11 at 11:30 A.M., she indicated the only other allegation of abuse that she was aware of was on a form she had found in DON #1's office (old DON who now is on leave and will return as a floor nurse). The HFA went to the Business Office Manager's office and returned with the three notes at this time. The HFA indicated she had just found it lately and was starting an investigation. There were 3 notes stapled together. Note 1 written by CNA #3, dated 7/7/11, indicated: "Resident H's family member made complaint that CNA #7 was very rough and rude with Resident H last night. CNA #7 allegedly came in to put her to bed and said something along the lines of what do you think you are doing? When Resident H asked who she was talking about CNA #7 said you know what you did. Resident H says that CNA #7 was easy about undressing her and preparing her for bed. Resident H's family member is very upset and would like to speak to HFA as soon as possible. According to her this was an issue in the past." Note 2- dated 8/16/11 2:20 p.m., written by the HFA indicated "Spoke with CNA #7 about this note, told her I was accusing (sic) her of anything, all CNA's are going to keep their resident dry and safe. She was ok when she left office." Note 3- written by CNA #7, no date, indicated "FYI- CNA on days, every morning before I go home I check my people second of all me and CNA #8 had split up sections I never leave any of my residents wet or dirty so you need to talk with someone else or don't accuse me of leaving anyone soaked because I don't do that." (sic) The HFA indicated on 8/17/11 at 11:30 A.M., she had received no other reports of abuse. When asked about the allegations made by CNA #9 to her charge nurse and to the HFA that a.m., the HFA indicated she had not had time to investigate it yet. She further indicated she did not consider what was reported to her abuse. Nurse Consultant #1 indicated it was considered abuse and CNA #5 would be sent home pending investigation. The HFA further indicated when she took over the facility it was a mess and she was trying to clean it up. She indicated she had not documented some of the things done because there was not time to look into things and document them. She indicated if she suspended all the staff accused of abuse there be no one to work. 6. On 8/17/11 at 2:00 P.M., CNA # 10 provided a written statement, dated 8/17/11, which indicated "To whom it may concern, I (CNA # 10's name) saw CNA # 1 handle Resident (Resident J's name) in an unprofessional manner. She was rough when turning resident, didn't explain what she was doing to the resident, left B.M. (bowel movement) on bed and resident. We were doing walk thru at shift change. She also treated (Resident K's name) in room (number) the same way, never explained what was going on with them, turned him, and changed him in a rough manner, again no peri care. I had to go behind her after she left and clean said residents. This is before I left in July 2011... (on vacation)." During interview with CNA #10 at this same time, she indicated this had been reported to the HFA, and was before CNA #1 was suspended for other allegations of abuse. The Immediate Jeopardy that began on 6/22/11 was removed on 8/19/11, when the facility demonstrated policies and procedures had been put in place to ensure staff were knowledgeable concerning the abuse protocol which included how to report abuse and the procedures for investigating, but noncompliance remained at the lower scope and severity of widespread, no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. This federal tag relates to Complaint IN 518. 3.1-28(c) 3.1-28(d)

Based on interview, record review and observation, the facility failed to ensure residents were free from abuse, for 12 of 13 residents reviewed for abuse. This had the potential to affect all 30 of 30 residents residing within the facility. Resident A, B, C, D, F, G, H, I, J, K, L, M. The Immediate Jeopardy began on 6/22/11 when abuse of a resident by a staff member was reported to have occurred in the facility. The Corporate Registered Nurse Consultant was notified of the Immediate Jeopardy at 1:00 P.M. on 8/17/11. The immediate jeopardy was removed on 8/19/11, but non-compliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During interview with the Health Facility Administrator (HFA) on 8/17/11 at 9:15 A.M., she indicated she had reported an allegation of abuse to the state agency and provided the documentation she had faxed in as well as the investigation of the allegations. She indicated the two Certified Nursing Assistants, CNA #1 and CNA # 2, involved had been fired. A note from CNA #4, dated 6/29/11, indicated "Back when name of Resident D, was put on fluid restriction, she was wanting more to drank (sic) there was some confusion with whether or not she could have more. She, Resident D, asked for a glass of milk, the nurses said it was ok, CNA #1 then brought her 2 glasses of milk sat them on the table in front of her and said something to this effect if she wants to kill herself let her go ahead and drink all that she wants." During interview with CNA #4, on 8/18/11 at 2 p.m., she indicated CNA #1 had said within hearing of Resident D to the effect of "go ahead and kill yourself it's ok with me." A written statement from CNA #3, dated June 29, 2011, indicated "I have witnessed CNA #2 and CNA #1 use excessive force on Resident B while tending to him. I have also been a witness to CNA #1 speaking very rudely to him. I have not witnessed either of them strike Resident B but there was an occurrence when I believe I heard CNA #1 slap Resident B in his room while my back was turned. I asked CNA #1 what happened immediately after. She was defensive and said he wouldn't let go of me. She never confirmed or denied slapping Resident B." During interviews with Physical Therapy Assistant (PTA #1) on 8/17/11 at 9:30 A.M. and 2:30 P.M., he indicated CNA #3, told him in the car that CNA #2 had punched a resident in the face. He indicated CNA #3 had later changed it to CNA #1. PTA #1 indicated this was on a Friday night, he thought 6/22/11. The HFA provided employee counseling forms, on 8/17/11 at 10:00 A.M. The employee counseling form, dated 6/29/11, for CNA #1 indicated "suspension 2 or 3 days, upon investigation, reported by CNA that CNA #1 was very rude and used excessive force while moving resident on or around 6/23/11. CNA did not witness either CNA which was CNA #2, strike the resident but she believes she heard a slap. CNA #1 did not deny slapping resident." Another form, dated 7/1/11, for CNA #1, indicated "Discharge due to speaking with Residents and staff members. I have decided to Discharge CNA #1." An employee counseling form for CNA #2, dated 7/1/11, indicated "Discharge, excessive force when moving residents, also not reporting to DON (Director of Nursing) or HFA. CNA #2 used excessive force when moving resident also did not report team member who also used excessive force when moving a resident...." 2. During interview with CNA #9 on 8/17/11 at 10:15 A.M., CNA #9 indicated CNA #3 had told her a couple of months ago that CNA #2 and CNA #1 had smacked Resident B. CNA#9 indicated she had reported to her charge nurse and the HFA that morning (8/17), what she thought was abuse that she observed the day before on 8/16/11. CNA #9 indicated on 8/16/11, her and CNA #6 heard Resident 'I' screaming from the shower room. CNA #9 indicated CNA #5 had been giving the resident a shower but had left her alone in the shower room without a call bell. CNA #9 indicated her and CNA #6 went to see what was wrong and had dressed Resident 'I' and transferred her to her chair. CNA #9 indicated CNA #5, upon returning to the shower room had asked them what they were doing. When they (CNA #9 and #6) told CNA #5 the resident had been screaming and they went to see what was wrong, CNA #5 went into the hall and told the resident 'Don't you never ever start screaming like that again.' " CNA #9 further indicated Resident D, Resident C and Resident F all had complaints concerning treatment by CNA #5. CNA #9 indicated Resident F was out of the facility at this time for an appointment. CNA #9 indicated Resident F was very concerned with conserving water and had asked CNA #5 to turn her water off and CNA #5 had became upset. Resident F then asked CNA #9 and #10 to provide her care as CNA #5 had given her a dirty look and was hateful and she did not want her providing care again. Resident F's clinical record was reviewed on 8/17/11 at 11:00 A.M. The MDS (Minimum Data Set) assessment, dated 7/28/11, indicated Resident F had no problems with cognition. Resident F required limited assistance of one with bed mobility, extensive assistance of one with bathing and was dependent with toilet use. CNA #9 further indicated that Resident D had told her some time back that CNA #5 was getting her up with a stand lift and her foot fell off. When Resident D complained, CNA #5 accused her of whining and told Resident D not to ever ask her for anything again. CNA #9 indicated Resident D does not want CNA #5 providing care for her. She indicated this is not written anywhere, but just common knowledge among the CNA's. On 8/17/11 at 9:30 A.M., CNA # 5 was observed in a resident room providing care. 3. During an interview with Resident D on 8/17/11 at approximately 10:30 A.M., she indicated CNA #5 had told her she did not like her, will not come into her room or do anything for her. She indicated if she asked for anything, CNA #5 would turn her head or just say,"No." Resident D indicated she had asked for milk, and CNA #5 looked at her and said "No." Resident D indicated she had told the HFA about this and the HFA brought CNA #5 into the room, and CNA #5 simply denied ever doing anything. Resident D's clinical record was reviewed on 8/17/11 at 1:00 P.M. The MDS (Minimum Data Set) assessment of 7/13/11, indicated Resident D had no problems with cognition. Resident D required extensive assistance of two with bed mobility, and was dependent on two staff with transfers and toilet use. In an interview with Resident C on 8/17/11 at 10:25 A.M., he was observed to be in bed with his cat on the bed beside him. He indicated CNA # 5 was very rough in handling him. He indicated CNA # 5 was very rude and talked down to him. He also indicated CNA # 6 had a chip on her shoulder and was mean during care. He further indicated he had reported this to the Administrator, but she didn't do anything. He indicated after reporting this to the Administrator she had told him his pet cat that had lived with him at the facility for 5 years had to go. He indicated he had banned CNA # 5 from providing any care for him. The clinical record for Resident C was reviewed on 8/17/11 at 1:20 P.M. The record indicated Resident C had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/15/11, indicated Resident C had no impairment in cognition. Resident C required extensive assistance of two with bed mobility and toilet use. The Nurse's Notes, dated 8/12/11 at 11:00 P.M., indicated "Asked me if I knew about his cat, was very upset about having to lose her." In an interview with Resident G, on 8/17/11 at 11:00 A.M., she indicated CNA # 5 was "always talking down to me." She stated CNA # 5 would always make comments about her clothing and how she combed her hair. She stated "I didn't want her to talk to me that way. I want to do as much as I can for myself." She also indicated she was a minister, and she stated that RN # 1 had called her the devil. She was very upset and misty eyed and asked "Why would she do something like that? I am not a bad person." The MDS (Minimum Data Set) assessment, dated 7/13/11, indicated Resident G had moderately impaired cognition. Resident G was independent with bed mobility, transfers, and ambulation. Resident G required limited assistance of one with toilet use and personal hygiene. 4. During interview with the HFA on 8/17/11 at 11:30 A.M., she indicated the only other allegation of abuse that she was aware of was on a form she had found in DON #1's office (old DON who now is on leave and will return as a floor nurse). The HFA went to the Business Office Manager's office and returned with the three notes at this time. The HFA indicated she had just found it lately and was starting an investigation. There were 3 notes stapled together. Note 1 written by CNA #3, dated 7/7/11, indicated: "Resident H's family member made complaint that CNA #7 was very rough and rude with Resident H last night. CNA #7 allegedly came in to put her to bed and said something along the lines of what do you think you are doing? When Resident H asked who she was talking about CNA #7 said you know what you did. Resident H says that CNA #7 was easy about undressing her and preparing her for bed. Resident H's family member is very upset and would like to speak to HFA as soon as possible. According to her this was an issue in the past." 5. During interview with Resident A's family on 8/17/11 at 12:00 P.M., they indicated while visiting at supper time, RN #1 was heard to be very hateful with Resident A. The family of Resident A further indicated that yesterday (8/16) they had heard CNA #5 yell at Resident L to get back in the bed and she would get to her when she could. The family further indicated Resident M was a longtime friend of their family. Resident A's family had given a phone number for them to Resident M. This was taken away by the HFA and Resident M told she was not allowed to have the number or call the family. Resident A's family indicated Resident M was scared to talk about it now and they had provided the number again and told her to keep it hid. 6. On 8/17/11 at 2:00 P.M., CNA # 10 provided a written statement, dated 8/17/11, which indicated "To whom it may concern, I (CNA # 10's name) saw CNA # 1 handle Resident (Resident J's name) in an unprofessional manner. She was rough when turning resident didn't explain what she was doing to the resident left B.M. (bowel movement) on bed and resident. We were doing walk thru at shift change. She also treated (Resident K's name) in room (number) the same way, never explained what was going on with them turned him and changed him in a rough manner again no peri care. I had to go behind her after she left and clean said residents. This is before I left in July 2011 (for vacation)...." During interview with CNA #10 at this same time, she indicated this had been reported to the HFA, and was before CNA #1 was suspended for other allegations of abuse. The Abuse Prevention Program, policy and procedure, dated 8/2006, provided by the Health Facility Administrator, on 8/17/11 at 10:00 A.M., indicated, "Abuse Reporting...will have no tolerance with anyone not reporting and following the 7 steps of abuse, neglect and exploitation...when any allegation or confirmed abuse occurs...With any allegation or suspected or witnessed abuse every employee has a legal obligation to report the occurrence." The Immediate Jeopardy that began on 6/22/11 was removed on 8/19/11, when the facility demonstrated policies and procedures had been put in place to ensure staff were knowledgeable about the abuse protocol, but noncompliance remained at the lowered scope and severity of widespread, no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. This federal tag relates to Complaint IN 518. 3.1-27(a)(1) 3.1-27(b)

Based on interview, record review and observation, the facility failed to ensure the health facility administrator responded to allegations and reports of resident abuse immediately by initiating an investigation, protecting residents during the investigation by not allowing accused staff members to continue working, reporting all allegations to the state agency, and documenting all allegations, for 7 of 13 residents reviewed for abuse. This had the potential to affect all 30 residents residing within the facility. Residents D, B, I, C, H, J, and K The Immediate Jeopardy began on 6/22/11 when a staff member alleged abuse was occurring in the facility. The HFA did not immediately suspend staff members accused of abuse or complete a thorough investigation of the allegation. The HFA did not document or investigate residents' complaints against staff members thoroughly, nor insure all staff were aware of the policy and procedure for allegations of abuse. The Corporate Registered Nurse Consultant was notified of the Immediate Jeopardy at 1:00 P.M. on 8/17/11. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During interview with the Health Facility Administrator (HFA) on 8/17/11 at 9:15 A.M., she indicated she had reported an allegation of abuse to the state agency and provided the documentation she had faxed in as well as the investigation of the allegations. She indicated the two Certified Nursing Assistants, CNA #1 and CNA #2, involved had been fired. She indicated she had no documentation of an inservice provided to staff members and had not obtained statements from all staff members who had worked with the two CNA's accused of abuse. She indicated she knew her staff and knew no one else was abusing anyone. She had talked with each staff member one on one about the policy for abuse, just had not written anything down. The HFA indicated when she had become aware of the situation, she had told the Director of Nursing (DON) to suspend CNA #1, but she found out a couple days later she had suspended CNA #2. The HFA indicated the DON had told her CNA #2 was also involved and that was the first the HFA knew about CNA#2's involvement. She indicated both CNA's were fired, CNA #1 for abuse and CNA #2 for witnessing it and not reporting it. The HFA indicated that was the company policy. The HFA indicated she could not remember when either of the CNA's were suspended but would try to find the dates. The incident reporting form, 5 day follow-up, dated as having been faxed, 6/29/11 at 12:47 P.M., indicated "Reported by: HFA name, Resident B, Diagnoses: [REDACTED].#3 that CNA #1 was rude and used excessive force when moving resident on or around 6/23/11. Immediate Action Taken: Suspension of employee. Resident assessed and reinterpreted (sic). Initiated interviews for other alert and oriented residents. Preventative measures taken: ANE (abuse/neglect) inservice schedule. Follow up-unable to substantiate, CNA #1 denies the allegations and with interviews could not substantiate the report. Employee has been terminated." Statements obtained from staff members included: "CNA #4, dated 6/29/11, Just to bring to attention that (CNA #2 name) in my personal opion (sic) is a little aggressive with personal care to residents. Maybe a fast turn her (sic) or a little bit hard to the other side. (sic) I personally would not have her take care take of my grandma." Another note from CNA #4, dated 6/29/11, "Back when name of Resident D was put on fluid restriction, she was wanting more to drank (sic) there was some confusion with whether or not she could have more. She, Resident D, asked for a glass of milk, the nurses said it was ok, CNA #1 then brought her 2 glasses of milk sat them on the table in front of her and said something to this effect if she wants to kill herself let her go ahead and drink all that she wants." During interview with CNA #4, on 8/18/11 at 2 p.m., she indicated CNA #1 had said within the hearing of Resident D to the effect of "go ahead and kill yourself its ok with me." CNA #4 indicated she did not report it at the time because a charge nurse heard it, too. CNA #4 could not remember what nurse for sure but thought it was DON #1. CNA #4 indicated she wrote the statements concerning CNA #1 and #2 on 6/29/11, because the HFA asked her to document anything she knew had occurred with those CNA's. A written statement, from CNA #3, dated June 29, 2011, indicated " I have witnessed CNA #2 and CNA #1 use excessive force on Resident B while tending to him. I have also been a witness to CNA #1 speaking very rudely to him. I have not witnessed either of them strike Resident B, but there was an occurrence when I believe I heard CNA #1 slap Resident B in his room while my back was turned. I asked CNA #1 what happened immediately after. She was defensive and said he wouldn't let go of me. She never confirmed or denied slapping Resident B." A written statement from PTA #1, dated 7/18/11, indicated, "I received a call from CNA #3 on 7/18/11 at approximately 9 p.m. in regards to repeated phone calls from CNA #1 and CNA #2...CNA #3 told me that they had been harassing her and threatening to find her and harm her. She also informed me that CNA #2 had told her that she was going to call corporate and tell them that she had caught us having sex in the building to try and get us (me and CNA #3) fired, since we had according to CNA #2 gotten her and CNA #1 fired. So today I addressed this with HFA...." During interviews with PTA #1 on 8/17/11 at 9:30 A.M. and 2:30 P.M., he indicated CNA #3 told him, while riding in a car, that CNA #2 had punched a resident in the face. He indicated CNA #3 later changed it the CNA #1. PTA #1 indicated this was on a Friday night, he thought 6/22, because there was a going away party for a nurse he and other staff members attended. He indicated he told the DON on Sunday when he came to work as he did not work on Saturday. PTA #1 indicated he remembered talking to the HFA about this on he believed Monday, but did not write anything down and was not asked to write a statement. PTA #1 indicated he thought the HFA then had CNA #3 write something up the next time she was at work. The HFA provided employee counseling forms on 8/17/11 at 10:00 A.M. The HFA further indicated at this time, the DON had not called her on 6/24/11 and told her about the PTA's report of allegations made by CNA #3 on 6/22/11. the employee counseling form, dated 6/29/11, for CNA #1 indicated "Suspension 2 or 3 days, upon investigation, reported by CNA that CNA #1 was very rude and used excessive force while moving resident on or around 6/23/11. CNA did not witness either CNA which was CNA #2, strike the resident but she believes she heard a slap to slap. CNA #1 did not deny slapping resident. State report filed 6/29/11." Another form, dated 7/1/11, for CNA #1, indicated "Discharge due to speaking with Residents and staff members. I have decided to Discharge CNA #1." An employee counseling form for CNA #2, dated 7/1/11, indicated "discharge, excessive force when moving residents, also not reporting to DON or HFA. CNA #2 used excessive force when moving resident, also did not report team member who also used excessive force when moving a resident-this was a state reportable on 6/29/11. I gave a 3 day suspension for investigation of this matter." No date as to when the 3 day suspension was documented. The facility Office Manager, on 8/18/11 at 1:00 P.M., indicated CNA#1 worked 6/23, 25, 26, 29 with her last day to work as 6/30/11. CNA #2 worked 6/22, 26, with the last day to have worked, 6/27/11. The facility lacked evidence of having reported rough treatment of [REDACTED]. In an in interview with Resident B's spouse, on 8/17/11 at 12:30 P.M., she indicated she had not been informed of the alleged abuse to Resident B. She stated a CNA had let this slip to her one day. She stated the CNA had said "I can't believe you didn't move your husband." She stated when I asked her why she said that the CNA said "you didn't know about CNA # 1 slapping him?" She stated she then went to speak to the Administrator and the Director of Nursing and got two different stories of the incident. The clinical record for Resident B was reviewed on 8/17/11 at 9:30 A.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 7/6/11, indicated Resident B had short and long term memory problems and severely impaired decision making. Resident B required extensive assistance of one with bed mobility, and extensive assistance of two with transfers and toilet use. 2. During interview with CNA #9 on 8/17/11 at 10:15 A.M., CNA #9 indicated she had reported to her charge nurse and the HFA that morning (8/17), what she thought was abuse that she observed the day before (8/16). CNA #9 indicated on 8/16/11, her and CNA #6 heard Resident 'I' screaming from the shower room. CNA #9 indicated CNA #5 had been giving the resident a shower, but had left her alone in the shower room without a call bell. CNA #9 indicated her and CNA #6 went to see what was wrong and had dressed Resident 'I' and transferred her to her chair. CNA #9 indicated CNA #5, upon returning to the shower room, had asked them what they were doing. When they (CNA #9 and #6) told CNA #5 the resident had been screaming and they went to see what was wrong, CNA #5 went into the hall and told the resident 'Don't you never ever start screaming like that again.'" CNA #9 indicated she told her charge nurse, LPN #1 this morning, 8/17/11. She indicated LPN #1 told her to go tell the HFA when she (the Administrator) got to the facility, which she had done and provided the HFA a write up on it. CNA # 9 was observed working in the facility on 8/17/11 at 11:00 A.M. During an interview with Resident D on 8/17/11 at approximately 10:30 A.M., she indicated CNA #5 had told her she did not like her, will not come into her room or do anything for her. She indicated if she asked for anything, CNA #5 would turn her head or just say, "No." Resident D indicated she had asked for milk, and CNA #5 looked at her and said "No." Resident D indicated she had told the HFA about this and the HFA brought CNA #5 into the room, and CNA #5 simply denied ever doing anything. Resident D's clinical record was reviewed on 8/17/11 at 1:00 P.M. The MDS (Minimum Data Set) assessment of 7/13/11, indicated Resident D had no problems with cognition. Resident D required extensive assistance of two with bed mobility, and dependent on two staff with transfers and toilet use. In an interview with Resident C on 8/17/11 at 10:25 A.M., he was observed in bed with his cat beside him. He indicated CNA # 5 was very rough in handling him. He indicated CNA # 5 was very rude and talked down to him. He also indicated CNA # 6 had a chip on her shoulder and was mean during care. He further indicated he had reported this to the Administrator, but she didn't do anything. He indicated after reporting this to the Administrator, she had told him his pet cat that had lived with him at the facility for 5 years had to go. He indicated he had banned CNA # 5 from providing any care for him. The clinical record for Resident C was reviewed on 8/17/11 at 1:20 P.M. The record indicated Resident C had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/15/11, indicated Resident C had no impairment in cognition. Resident C required extensive assistance of two with bed mobility and toilet use. The Nurse's Notes, dated 8/12/11 at 11:00 P.M., indicated "Asked me if I knew about his cat, was very upset about having to lose her." On 8/17/11 at 9:30 A.M., CNA # 5 was observed in a resident room providing care. 4. During interview with LPN #1, on 8/17/11 at 11:15 A.M., she indicated she had told CNA #9 to tell the HFA when she got there that morning about the incident with CNA # 5 and Resident 'I'. She confirmed that CNA #5 was still working at that time. LPN #1 indicated that she had only been working for 5 or 6 days and really did not know what the abuse protocol was. She indicated she just had not had a chance to attend general orientation. LPN #1's employee file was obtained from the Office Manager on 8/17/11 at 12:00 P.M. Documentation of training in the facility abuse protocol was lacking. The last 10 hired employees files were reviewed, on 8/17/11 at 1:00 P.M. Three of the 10 new employees had not been trained in the facility abuse protocol. 5. During interview with the HFA on 8/17/11 at 11:30 A.M., she indicated the only other allegation of abuse that she was aware of was on a form she had found in DON #1's office (old DON who now is on leave and will return as a floor nurse). The HFA went to the Business Office Manager's office and returned with the three notes at this time. The HFA indicated she had just found it lately and was starting an investigation. There were 3 notes stapled together. Note 1 written by CNA #3, dated 7/7/11, indicated: "Resident H's family member made complaint that CNA #7 was very rough and rude with Resident H last night. CNA #7 allegedly came in to put her to bed and said something along the lines of what do you think you are doing? When Resident H asked who she was talking about CNA #7 said you know what you did. Resident H says that CNA #7 was easy about undressing her and preparing her for bed. Resident H's family member is very upset and would like to speak to HFA as soon as possible. According to her this was an issue in the past." Note 2- dated 8/16/11 2:20 p.m., written by the HFA indicated "Spoke with CNA #7 about this note, told her I was accusing (sic) her of anything, all CNA's are going to keep their resident dry and safe. She was ok when she left office." Note 3- written by CNA #7, no date, indicated "FYI- CNA on days, every morning before I go home I check my people, second of all me and CNA #8 had split up sections I never leave any of my residents wet or dirty so you need to talk with someone else or don't accuse me of leaving anyone soaked because I don't do that." (sic) The HFA indicated on 8/17/11 at 11:30 A.M., she had received no other reports of abuse. When asked about the allegations made by CNA #9 to her charge nurse and to the HFA that a.m., the HFA indicated she had not had time to investigate it yet. She further indicated she did not consider what was reported to her abuse. Nurse Consultant #1 indicated it was considered abuse and CNA #5 would be sent home pending investigation. The HFA further indicated when she took over the facility it was a mess and she was trying to clean it up. She indicated she had not documented some of the things done because there was not time to look into things and document them. She indicated if she suspended all the staff accused of abuse there be no one to work. 6. On 8/17/11 at 2:00 P.M., CNA # 10 provided a written statement, dated 8/17/11, which indicated "To whom it may concern, I (CNA # 10's name) saw CNA # 1 handle Resident (Resident J's name) in an unprofessional manner. She was rough when turning resident, didn't explain what she was doing to the resident, left B.M. (bowel movement) on bed and resident. We were doing walk thru at shift change. She also treated (Resident K's name) in room (number) the same way, never explained what was going on with them, turned him and changed him in a rough manner, again no peri care. I had to go behind her after she left and clean said residents. This is before I left in July 2011 (for vacation)..." During interview with CNA #10 at this same time, she indicated this had been reported to the HFA, and was before CNA #1 was suspended for other allegations of abuse. 7. During interview with the RN Nurse consultant on 8/17/11 at 1:00 P.M., she indicated the HFA had just left the facility and quit without notice. The Abuse Prevention Program, policy and procedure, dated 8/2006, provided by the Health Facility Administrator, on 8/17/11 at 10:00 A.M., indicated, "Abuse Reporting...will have no tolerance with anyone not reporting and following the 7 steps of abuse, neglect and exploitation...when any allegation or confirmed abuse occurs, the appropriate state agencies need to be notified, and the DON and Administrator...need to check and see if this or any other thing has happened to any other resident...With any allegation or suspected or witnessed abuse every employee has a legal obligation to report the occurrence. The Abuse policy, dated 3/11, for Protocols for investigating, included: "Any employee who suspects an alleged violation shall notify the HFA/ DNS (director of nursing services)...immediately...the facility will investigate each allegation thoroughly and report the results to the HFA...the DNS shall notify the residents representative regarding the alleged incident. Inform the representative that an investigation has been initialed and appropriate actions will be taken...document this contact in the clinical record...if the suspect is an employee, they shall be placed on immediate suspension pending the results of the investigation...if the allegation involves physical abuse...a background check will be conducted to determine if any disqualifying offenses have occurred since the previous check...The investigation shall include interviews of employee, visitors or residents who may have knowledge of the alleged incident. Written documentation will be kept of each interview taken. The employee, resident or visitor may write their own report if desired...written statements form involved parties should be based on facts not opinions...training -orientation and ongoing in service training." The Immediate Jeopardy that began on 6/22/11 was removed on 8/19/11, when the facility demonstrated policies and procedures had been put in place to ensure staff were knowledgeable concerning the duties of the facility administration, but noncompliance remained at the lowered scope and severity of widespread no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. This federal tag relates to Complaint IN 518. 3.1-13(q)