Every finding on record at Corydon Specialty Care

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure residents received timely feeding assistance for 2 of 2 residents reviewed for nutrition (Residents #21 and #37). The facility reported a census of 56 residents.Findings:1. Resident #21's Minimum Data Set (MDS) assessment, dated 12/11/25, identified a Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. The MDS listed Resident #21 as dependent on staff for eating. The MDS included diagnoses of Alzheimer's, non-Alzheimer's dementia, and Parkinson's disease (a disease which caused stiffness and tremors). The Care Plan Focus dated 10/3/25 related to activities of daily living (ADL's) included an Intervention that Resident #21 required staff assistance of 1 with eating.The Dietary Note dated 12/11/25 at 10:06 AM reflected the staff assisted Resident #21 with eating.On 1/26/26 at 12:15 PM, observed Resident #21 with a plate of food (breaded fish and mashed potatoes) in front of her. The staff didn't assist her with eating after the delivery of her plate. Resident #21 didn't eat herself until 12:26 PM when she tore a small bite of fish off the filet with her fingers and placed it in her mouth. Resident #21 didn't eat anything else by herself. The staff didn't assist her until 12:31 PM when Staff A, Certified Nursing Assistant (CNA), began to help her.2. Resident #37's MDS assessment dated [DATE], identified a BIMS score as 4 out of 15, indicating severely impaired cognition. Resident #37 required supervision or touch assistance, a helper provided verbal cues and/or touching/steadying and/or contact guard assistance until the resident finished the activity, with eating. The MDS included diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and unspecified macular degeneration (a condition which resulted in a distortion or loss of central vision).The Care Plan Focus dated 10/3/23 related to ADLs included an Intervention that Resident #37 required setup assistance with verbal cues and oversight as needed for eating.The Nutritional assessment dated [DATE] reflected Resident #37 fed herself with setup assistance/supervision.The Dietary Note dated 1/19/26 at 8:41 AM indicated Resident #37 fed herself with supervision.The untitled Kardex (an at-a glance Care Plan staff used for reference) as of 1/29/26 directed Resident #21 required setup assistance and verbal cues with oversight.On 1/26/26 at 12:22 PM, Resident #37 attempted to remove the lid of her ice cream container. Resident #37 continued to attempt to remove the lid without success until a dietary staff member came over and helped her at 12:31 PM. At the time, Resident #37 attempted with one hand to get the top off without success. At 12:34 PM, Resident #37 struggled to take a bite out of the ice cream container and pushed her ice cream over to a male resident who sat at her table. Resident #37 continued to struggle getting a bite out and at 12:42 PM, she placed a large spoonful of ice cream into her glass of water and then ate it. During that time, Staff A and Staff B, CNA, sat at other tables assisting other residents and didn't appear to notice Resident #37 had ice cream in her water. From 12:22 PM until 12:44 PM, the staff didn't assist or encourage Resident #37 to eat. Resident #37 only ate a few bites of her ice cream with difficulty. At 12:44 PM Staff C, Licensed Practical Nurse (LPN), asked Resident #37 if her lunch was good but didn't assist her. At 12:45 PM, Staff B sat down and assisted Resident #37 with eating.The facility policy Assistance with Meals, revised 2017, instructed to assist residents with meals in a manner that met the individual needs of each resident.On 1/29/26 at 8:21 AM, via phone, Staff B described Resident #21 as dependent on staff because she couldn't lift the spoon to her mouth. She stated she tried to look over at Resident #37 during meals but didn't know if she did on 1/26/26. On 1/29/26 at 8:36 AM, Staff D, CNA, stated Resident #37 required staff assistance to set up her food including opening ice cream containers. Staff D stated Resident #37 may not be interested in eating but she got mad if staff encouraged her to eat. Staff D stated she did approach Resident #37 and got her to smile and eat.On 1/29/26 at 8:58 AM, Staff E, CNA, stated if staff delivered a resident's tray, they should assist them in a timely manner. She stated Resident #37 required prompting by the staff and it didn't bother her. Staff E stated she observed Resident #37 mix her food, for example she put her cereal in her water. She stated when this occurred, staff would direct her what to eat. She stated they kept an eye on Resident #37 while she ate.On 1/29/26 at 9:13 AM, Staff A stated staff fed one resident then moved on to another resident. She stated they usually had 3 staff in the dining room but if one needed to leave (to provide care for a resident) it could be tough. She stated they kept an eye on Resident #37 during meals as she needed prompts.On 1/29/26 at 10:01 AM, the Director of Nursing (DON) stated staff try to start feeding residents within 10 minutes after staff delivered the tray. She stated Resident #21 needed assistance from staff to eat. She stated if Resident #37 mixed her food, the staff should attempt to intervene. She stated they need to work on staff providing assistance in the dining room.

Based on clinical record review and staff interviews, the facility failed to provide a private pay resident being discharged to another facility, their unused medications and controlled medications (Resident #2). The facility census was 52 residents. Findings include: According to a Minimum Data Set (MDS) with a reference date of 12/6/24, Resident #2 had a Brief Interview for Mental status (BIMS) score of 13, indicating an intact mental status. Resident #2 required dependent assistance with transfers, mobility, dressing, toilet use, and personal hygiene needs and was frequently incontinent of bladder. Resident #2's diagnoses included cerebrovascular accident (stroke), congestive heart failure, atrial fibrillation, renal insufficiency, arthritis, and gastroesophageal reflux disease. Review of Resident #2's June medication administration record (MAR) found her to be prescribed several medications to control pain and anxiety including Lyrica 50 milligrams daily at night, Hydrocodone/Tylenol 5/325 milligrams every 6 hours as needed for pain, and Lorazepam 0.5 mg every 12 hours as needed for anxiety. The June MAR demonstrated the use of as needed Hydrocodone/Tylenol 5/325 milligrams was generally two doses a day with the last dose given on 3/11/25 at 10:10 a.m. In an interview on 6/24/25 at 10:00 a.m. the Administrator from the facility in which Resident #2 was transferred to on 3/11/25, stated when Resident #2 arrived, she was without any of her medications, including pain medications which she relied upon to control her pain. The Administrator stated she contacted the facility and was informed their protocol on discharge was to send back prescribed medications and to destroy controlled medications. The Administrator informed the facility that the resident was private pay and paid for her medications and therefore the medications were her property and they did not have the right to withhold or destroy her medications. The Administrator stated in addition, because the medications were recently refilled, Resident #2's insurance would not pay for re-fills, leaving her without any pain medication. The Administrator stated the following morning she went to their pharmacy and was able to get the refills, but noted Resident #2 was without pain mediations for over 10 hours. In an interview on 6/24/25 at 10:20 a.m. the Director of Nursing (DON) stated the normal process when discharging a resident would be to send back unused medications to the pharmacy and to destroy controlled medications. This was the process the facility followed when discharging Resident #2 to another facility. The DON stated Resident #2 was private pay and paid for her own medications. The DON stated on 3/11/25 they received a call from the receiving facility questioning where Resident #2's medications were? The DON stated she explained and the following day Resident #2's spouse drove up and picked up her medications. The DON noted the facility reimbursed Resident #2 for the controlled medications they destroyed. The DON stated she later was shown facility policy on Discharge Medications in which it was acceptable to send controlled medications with a discharged resident. The DON stated she was unaware of that policy until shown. According to the facilities Discharge Medications policy; #3. controlled substances shall not be released upon discharge of the resident unless permitted by current state law governing the release of controlled substances and as authorized (in writing) by the resident's attending physician.

Based on clinical record review, observations, policy review, and staff interviews the facility failed to protect residents from accidents and injuries to include failing to implement interventions to reduce risks for 1 of 3 residents (Resident #15) reviewed for falls. The facility reported a census of 51. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 9/5/24 documented an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented diagnosis of Alzheimer's Disease, anxiety disorder and muscle weakness. The MDS revealed total dependence of 2 or more helpers to complete oral, upper and lower body dressing, putting on/taking off footwear and partial to moderate assistance with sit to stand and transfers. The MDS also revealed the resident had fallen since the prior assessment and had injuries. Review of Resident #15's Care Plan with an initiation date of 12/18/22 revealed Resident #15 was at risk for falls. On 10/3/23 updated to required assistance of 1 with transfers. Care plan documented updates to risk for falls interventions/task on followings dates: 7/19/24 Offer to assist me with positioning at the dinner table. 8/26/24 Encourage me to carry Reacher in my wheelchair to retrieve items off the floor when out of my room. 11/24/24 Therapy to assess for new wheelchair cushion to ensure proper positioning. 12/5/24 Care Plan updated to assist resident with moving foot pedals back while sitting at the Dining Room table. The Incident Report dated 11/1/24 at 2:55 pm documented the resident was on her bottom next to the door that separates the dining room and bird room. The Five Whys Worksheet for the fall documented a new intervention for aides to assist resident in adjusting her foot pedals. The Incident Report dated 11/24/24 at 6:55 pm documented the resident was found on the floor under the wheelchair crying and stating she leaned forward and fell out of the chair. She stated she leaned forward and fell . The Five Whys Worksheet for the fall 11/24/24 documented the intervention for therapy to assess for wheelchair cushion that encourages appropriate positioning. The Incident Report dated 12/5/24 at 5:10 pm documented the resident was found on the dining room floor crying and had a jagged laceration to her head. A puddle of blood under the resident's head. The resident unable to state what happened. The report documented the wheelchair food pedals were forward. Review of the Electronic Healthcare Record (EHR) tab titled, Progress Notes, revealed the following falls and injuries: On 12/5/24 at 8:37 pm resident #15 was found by a staff member laying on the dining room (assist side) floor. Resident was crying. Resident had a jagged laceration to her head. A puddle of blood was on the floor underneath her head. Resident had shoes on both feet. Resident crying stating I'm sorry unable to describe what she was attempting to do. Resident assisted by EMS to wheelchair for treatment of laceration to head. Care Plan updated to assist resident with moving foot pedals back while sitting at DR table. On 11/24/24 at 9:20 pm resident found on the floor in the hallway under wheelchair. Crying stated leaned forward and fell out of chair. On 11/1/24 at 3:07 pm resident was found on the floor near the dining room and bird room. On 10/25/24 at 4:54 am resident complained of pain in her left forearm from a recent fall, area raised, pain upon palpitation. On 8/26/24 at 1:19 pm dietary staff observed resident attempting to reach for a muffin on the floor and fell to the floor, hitting her head on the table. On 7/20/24 at 12:43 pm resident fell to the floor in assisted dining side, wheelchair on the side, left pedal under her left hip. Resident told staff she was trying to pull left foot pedal back to scoot herself closer to the table. On 7/5/24 at 1:29 pm resident fell out of her wheelchair during a self-transfer. Injuries sustained to face: pink area to the forehead with blood noted by a staff member. During an observation on 12/10/24 at 10:45 am, Resident #15 noted to have an abrasion to her forehead. Observed the resident sitting in a wheelchair while she observed an activity. The wheelchair had 2 foot pedals locked in place while residents' feet rested on the floor. During the dining room (DR) observation on 12/10/24 from 12:00 pm to 1:00 pm, Resident #15 noted to self-propel in her wheelchair between dining room tables and after the meal service was completed, headed to her room, with the foot pedals locked in place, restricting her ability to extend her feet forward, causing her feet to tangle and bend under the wheelchair several times. Towards the end of this observation, a staff member approached the resident who by then partially slid towards the edge of the seat. The staff member placed Resident #15's feet onto the foot pedals and then assisted with the transfer. During the subsequent observation on 12/11/24 at 9:48 am, Resident #15 attended the activity in the common area, sitting in the wheelchair with the foot pedals locked in place, feet on the floor. During an interview on 12/11/24 at 9:57 am with Staff D, Certified Medication Aide (CMA), Staff D stated Resident #15 had frequent falls and slid out of her wheelchair often; recently therapy recommended a different seat cushion but it was not in place to her knowledge. Staff D, CMA further stated she would pull the resident up in the wheelchair if she saw her sliding out of it since the resident didn't have a strong core/torso. In an interview on 12/12/24 at 9:50 am with the Director of Rehabilitation, it was revealed that Resident #15 had been ordered a different cushion pad and there were some modifications made to her wheelchair. His knowledge of the Resident #15 included: staff assist with transferring since unable to lock the wheelchair on her own, history of sliding out of the wheelchair and poor safety awareness. Physical Therapy was attempted but unsuccessful due to Resident's physical limitations and only Occupational Therapy was in place. In an interview on 12/12/24 at 11:00 am with the Director of Nursing, she stated Resident #15 was able to reposition herself in the wheelchair and needed her foot pedals locked in place while she did it. After reviewing the Care Plan intervention dated 12/5/24 with the intervention to move foot pedals back while sitting at the DR table, she confirmed it was not followed by the facility staff. The facility provided policy titled Falls and Fall Risk, Managing revised March 2018, documented: Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observations, staff interviews, and policy review, the facility failed to ensure proper food handling and hand hygiene practices during meal service. The facility reported a census of 51. Finding include: During a continuous observation during lunch service on 12/10/24 at 12:00 PM, the following was observed: 1. Staff A, Certified Nursing Assistant, cutting and buttering a resident's dinner roll with bare hands. 2. Staff B, Van Driver (who is also a Certified Nursing Assistant), cutting and buttering a resident's dinner roll with bare hands. Staff B observed feeding a resident one bite, walking over to another resident, interacting with them and then feeding one bite to that resident. No hand hygiene observed in-between the two residents. Throughout lunch service, Staff B also seen placing hands in pant pockets and rubbing a resident's arm with no hand hygiene observed after these actions. Staff B continued to assist residents eating. 3. Staff C, Cook, cutting and buttering a resident's dinner roll with bare hands. Gloves and a working automatic hand sanitizer dispenser identified in the dining room and readily available for staff use. During an interview on 12/10/24 at 12:15 PM, the Certified Dietary Manager acknowledged staff should not be touching ready-to-eat food with bare hands. During an interview on 12/11/24 at 9:45 AM, the facility Administrator acknowledged the use of bare hands during the previous day's lunch service via a written note from one of the offending staff members. The Administrator also acknowledged a lack of hand hygiene observed throughout lunch. The policy Food Preparation and Service, revised April 2019 revealed, bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. The policy Hand Hygiene Procedure, version 2.3 (H5MAPL0362), documented the use of an alcohol-based hand rub or alternative soap and water should be used in the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents. c. After contact with objects. d. Before and after assisting a resident with meals.

Based on Electronic Health Record (EHR) review, staff interview, and policy review, the facility failed to consistently complete physician's order for weekly weights for 1 of 1 residents reviewed for nutrition (Resident #13). The facility reported a census of 51. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 with a Brief Interview for Mental Status score of 15 indicating intact cognition. Diagnoses included atrial fibrillation/other dysrhythmias, heart failure, peripheral vascular disease, and Parkinson's disease. The MDS indicated use of a diuretic. The Care Plan revised on 11/8/24 documented a significant weight loss for Resident #13 with a goal to maintain weight or have a slow and gradual weight loss towards a healthier Body Mass Index for age. Interventions include obtaining weights per facility policy. The Care Plan further documented diuretic therapy related to congestive heart failure. Review of the EHR for Resident #13 showed a physician order for weekly weights times 4 weeks. The Physician Order Form signed by the Nurse Practitioner as well as the charge nurse and dated 11/11/24. The Weights and Vitals summary obtained on 12/12/24 show the following weights: 10/1/2024 270.6 Lbs 10/15/2024 261.3 Lbs 10/22/2024 260 Lbs 10/29/2024 257.3 Lbs 11/1/2024 256.8 Lbs 11/5/2024 256.8 Lbs 11/12/2024 254.0 Lbs 12/3/2024 254.2 Lbs 12/10/2024 250.7 Lbs The EHR revealed lack of documented weights for the weeks of 11/19/24 and 11/26/24. No documentation found related to staff attempts to obtain weights, resident refusing, or notifying the Primary Care Provider (PCP) of missing weights. During an interview on 12/11/24 at 10:40 AM, the Director of Nursing (DON) explained charge nurses will review PCP order sheets and enter orders in the EHR. The DON acknowledged the oversight of obtaining Resident #13's weights as ordered and the lack of documentation as to why. The DON voiced an expectation that physician orders to be implemented and followed as written. The policy Medication Orders, revised November 2014, established guidelines in receiving and recording medications order, which include treatments. This should include the specific treatment, frequency, and duration of treatment.

Based on observation, photos, resident interview and staff interview the facility failed to maintain a safe, sanitary, odor free and homelike atmosphere. The facility identified a census of 52 residents. Findings include: 1. An observation 1.6.24 at 3:30 p.m. revealed a foul, long lasting urine odor throughout the facility. An observation 1.17.24 (throughout the entire day and afternoon) revealed a foul, long lasting urine odor throughout the building. During an interview 1.17.24 at 1:40 p.m. Staff B, Certified Nurses Aide (CNA) confirmed the foul, long lasting urine odor throughout the building. The staff member indicated she felt the odor came from the carpets. 2. An observation 1.17.24 at 3:02 p.m. revealed rough and jagged edges along a baseboard heating unit in room [ROOM NUMBER]. An observation 1.17.24 at 3:08 p.m. revealed rough and jagged edges along a baseboard heating unit in room [ROOM NUMBER].

Based on observation, photos, record review, resident interview, staff interview and facility policy review the facility failed to maintain an environment free of vermin. The facility identified a census of 52 residents. Findings include: During an interview 1/17/24 at 2:47 p.m. Staff A, Certified Nursing Assistant (CNA) indicated she found mouse droppings in the bed of Resident #6 on 12/22/23. The staff member also confirmed mouse droppings in room [ROOM NUMBER] currently and when occupied by residents. The staff moved the bedside stand in room [ROOM NUMBER] and stated she observed a mouse as it peaked it's head out of a hole in the corner of the wall. A photo time stamped 1/17/24 at 2:52 p.m. revealed mouse droppings along the baseboard located on the wall behind the bed and bedside stand in room [ROOM NUMBER]. A Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that Resident#5 scored a 15 out of 15 for a Brief Interview for Mental Status, which indicated intact cognitive skills for daily decision making. An observation 1/17/24 at 3:02 p.m. revealed mouse droppings behind the bedside stand for Resident #5. During an interview at the same time the Resident indicated two (2) days prior a mouse climbed up her wheel chair and just looked at her which scared her at the time. During an interview 1.18.24 at 8:10 a.m. Resident #5 indicated the mice returned last night and ran under her as she sat on the commode positioned along the wall beside her bedside stand in her room. The facility policy on Pest Control revised 5.2008 included the following interpretation and implementation: a. This facility maintained an on-going pest control program to ensure that the building had been kept free of insects and rodents.

Based on observation, clinical record review, staff interview, resident interview and facility policy review, the facility failed to properly provide perineal cares for 2 of 3 residents reviewed (Resident #1 and #4) and failed to reposition residents according to their individual desires and/or needs. (Resident #2) The facility identified a census of 52 residents. Findings include: 1. A Significant Change in Status Minimum Data Set (MDS) form dated 12/21/23 indicated Resident #1 had diagnosis that included cancer, Peripheral Vascular Disease (PVD) and a Right Below the Knee Amputation (BKA). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact) and required assistance of staff with his Activities of Daily Living (ADL's). A Care Plan indicated the resident had a Focus area of ADL's initiated 10/3/23. The Interventions included the following: a. The Resident required two (2) staff assistance with transfers and toileting An observation 1/17/24 at 1:25 p.m. revealed Staff C, Certified Nursing Assistant (CNA) and Staff B, CNA as they provided perineal care for the resident confirmed as incontinent by Staff C. Staff C provided the hands on perineal care but failed to cleanse the residents buttocks, hips and/or retract the resident's foreskin to properly cleanse his perineal area. During an interview 1/17/24 at 1:37 p.m. Staff B confirmed Staff C failed to properly cleanse the resident's entire perineal area as documented above. 2. A Admission MDS assessment form dated 1/4/24 indicated Resident #4 had diagnosis that included a Urinary Tract Infection (UTI), urinary incontinence and a Cerebrovascular Accident (CVA). The assessment indicated the resident had a BIMS score of 15 and required partial to moderate assistance of staff with toileting hygiene. A Care Plan indicated the resident had a Focus area of ADL's initiated 1/29/23. The Interventions included the following: a. Staff assistance with toileting and personal hygiene. An observation 1/17/24 at 12:45 p.m. revealed Staff C as she propelled the resident to her room per wheel chair, placed a gait belt (GB) assistive device, ambulated the resident from the doorway of the room to the bathroom, pulled down the resident's pants as the resident sat down on the toilet. The staff member confirmed the resident as incontinent of urine her brief and sweat pants. The staff member removed the soiled clothing and cleansed the resident's legs. The Resident then requested to perform her own anterior perineal care. Upon completion the resident stood as the staff member cleansed the resident's mid gluteal region but failed to cleanse the resident's buttocks and/or hips. 3. A Quarterly MDS assessment form dated 11.20.23 indicated Resident #2 had diagnosis that included morbid obesity. The assessment indicated the resident had a BIMS score of 15 and as dependent on staff with repositioning. During an interview 1/17/24 at 4:26 p.m. the resident confirmed she had been unable to reposition herself and the staff failed to reposition her on a consistent basis. 4. During an interview 1/17/24 at 1:10 p.m. Staff A, CNA confirmed staff as not able to reposition residents according to their individual needs due to (d/t) poor staffing levels. During an interview 1/17/24 at 1:40 p.m. Staff B indicated some residents are repositioned according to their individual needs and some were not as it all depended on the amount of staff scheduled. 5. A Repositioning policy revised 5/2013 included the following purpose: The purpose of the procedure had been to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents.

Based on resident interview, staff interview, resident council minutes, and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes for 2 of 4 residents reviewed. (Resident #2) The facility identified a census of 52 residents. Findings include: 1. During an interview 1/17/24 at 4:26 p.m Resident #2 indicated she had timed her call light on as long as one (1) hour while she used her cell phone which made her angry. The delayed response times also caused incontinence of urine which caused a feeling of embarrassment which she hated. Resident Council Minutes dated 12/7/23 documented that 12 residents attended the meeting, concerns had been expressed by the residents that call lights took too long to be answered. Resident#2 did not attend the meeting on 1/10/24. Resident Council Minutes dated 1/10/24 lacked follow up documentation to question the residents if call lights still remained a concern or not. Resident#2 did not attend the meeting, seven other residents did attend the meeting. During an interview 1/17/24 at 1:10 p.m. Staff A, Certified Nurse Aide (CNA) confirmed staff as not able to answer resident call lights within 15 minutes. The staff member indicated most of the time the CNA's worked with just two (2) CNA's and the facility had at least nine (9) residents who required 2 staff assistance with cares which left the other residents unattended when they cared for those residents. During an interview 1/17/24 at 1:40 p.m. Staff B, CNA indicated staff answered resident call lights to the best of their ability further described as no as it all had been dependent on the amount of CNA's scheduled on a given day. The staff member confirmed the past weekend residents had been left up for long periods of time, not repositioned and call lights not answered due to the failure of staff to report to work as scheduled due to the winter storm in the area. During an interview 1/17/24 at 2:03 p.m. Staff C, CNA confirmed staff failed to answer resident call lights within 15 minutes. During an interview 1/17/24 at 3:18 p.m. Staff D, CNA indicated staff answered resident call lights within 15 minutes 8 out of 10 times. The other 2 times staff assisted residents who required 2 staff assistance and had not been able to answer the call lights timely. The facilities policy on Answering a Call Light revised 3.2021 indicated the purpose as the following: a. Assurance of timely responses to the resident's requests and needs.

Based on observation, clinical record review, staff interview and review of Resident Rights the facility staff failed to treat 1 of 4 residents with dignity and respect while providing resident cares. (Resident #4) The facility identified a census of 52 residents. Findings include: A Admission Minimum Data Set (MDS) assessment form dated 1/4/24 indicated Resident #4 had diagnosis that included a Cerebrovascular Accident (CVA), Diabetes Mellitus (DM), Urinary Tract Infection (UTI) and anxiety. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact) and required staff assistance with activities of daily living (ADL's). A Care Plan addressed a Focus area of ADL's (initiated 12/29/23) with Interventions that included the following as dated: a. Assistance of one (1) staff member with personal hygiene and toileting (initiated 12/29/23) and two (2) staff assistance with transfers (initiated 1/29/23). An observation 1/17/24 at 12:45 p.m. revealed as Staff C, Certified Nursing Assistant (CNA) provided personal cares for the resident the Social Worker/Licensed Practical Nurse (LPN) knocked and walked into the resident's room without an invitation to have entered and after Staff C stated cares. During an interview 1/17/24 at 1:10 p.m. Staff A, Certified Nurse Aide (CNA) confirmed staff opened resident doors and walked right in without knocking and/or waiting for an invitation to enter while she provided personal cares to those residents. During an interview 1/17/24 at 1:40 p.m. Staff B, CNA confirmed she walked directly into resident rooms during cares and without knocking and waiting for an invitation to have entered. During an interview 1/17/24 at 2:03 p.m. Staff C, CNA confirmed staff always walked directly into resident rooms during personal cares and without knocking and waiting for an invitation. Review of the facilities Resident Rights revised 12/2016 directed the facility staff to have treated all residents with kindness, respect and dignity. The Policy and Interpretation and Implementation included the following: a. Privacy and confidentiality. b. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. c. Staff are expected to knock and request permission before entering a residents' room.

Based on clinical record review, resident interview and staff interview the facility failed to provide restorative exercises according to the resident's individual plan of care for 1 of 3 residents reviewed. (Resident #2) The facility identified a census of 52 residents. Findings include: A Quarterly Minimum Data Set (MDS) form dated 11.20.23 indicated Resident #2 had diagnosis that included anxiety, morbid obesity and a neoplasm of the aortic body and other paraganglia. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact) and required assistance of staff with Activities of Daily Living (ADL's). A restorative participation record form directed the facility staff to have performed Active Range of Motion (AROM) to the resident's upper extremities 3 to 6 times a week. The record included the following as dated: a. Not applicable - 12/24/23 and 12/28. b. Refused - 12/25/23, 1/.26, 12/27 and 1/10/24. During an interview 1/18/24 at 8:45 a.m. the resident denied having refused restorative exercises in and around Christmas and on the 1/10/24. The resident then began to cry and stated, they are lying and she wanted exercises. During an interview 1/17/24 at 1:10 p.m. Staff A, Certified Nurse aide (CNA) confirmed staff failed to provide restorative exercises to residents according to their individual programs. During an interview 1/18/24 at 9:35 a.m. Staff A confirmed she documented a check mark under the not applicable ( N/A) section of the facilities restorative documentation sheets when she failed to perform the individual residents restorative exercises due to staffing levels. During an interview 1/17/24 at 1:40 p.m. Staff B, CNA indicated the facility failed to staff a restorative aide so it had been impossible for the CNA's scheduled to have performed restorative exercises to all of the residents specially with only 2 CNA's scheduled. During an interview 1/18/24 at 9:43 p.m. Staff B indicated when she had been unable to perform restorative exercises she left the documentation blank. Management directed staff not to have placed a check mark in the N/A section because the residents never refused and were never offered restorative exercise. During an interview 1/17/24 at 2:03 p.m. Staff C, CNA confirmed when there had been only 2 CNA's staffed for a shift the staff failed to provide individual resident restorative programs as set up.

Based on record review, staff interviews, and Resident Assessment Instrument (RAI) Manual the facility failed to complete the Minimum Data Set (MDS) within 14 days of starting Hospice services for 1 of 1 resident's reviewed for Hospice services (Resident #33) . The facility reported a census of 51 Residents. Findings include: Record review of a document titled Election Of Medicaid Hospice Benefit dated 10/2/2023, informed Resident #33 elected Hospice Benefits on 10/2/23. Record review of Resident #33 Progress Review dated 10/2/23 at 1:49 PM documented he was admitted to Hospice Services with primary diagnosis of Alzheimer's disease. Record review of Resident #33 MDS dated [DATE] documented an assessment completion date of 10/23/23. During an interview with the MDS Coordinator on 12/21/23 at 12:15 PM revealed she would expect a significant change MDS to be completed within 14 days from the date identified. Review of the RAI Manual dated 10/1/23 instructs facilities to complete a Significant Change Assessment MDS within 14 days after determining criteria is met.

Based on record review and staff interviews the facility failed to code Preadmission Screening and Resident Review (PASRR) on 1 of 1 residents (Resident #46) comprehensive Minimum Data Set (MDS). The facility reported a census of 51 residents. Findings include: Record review of Resident #46 PASRR dated 4/20/2023 documented she was a PASRR Level II. The MDS dated [DATE] for Resident #46 documented she was not a PASRR Level II. Record review of Resident #46 Care Plan on 12/21/23 documented she was a PASRR Level II. During an interview on 12/21/23 at 12:17 PM the MDS Coordinator revealed Resident #46 MDS was coded wrong due to a keystroke error and she was a PASRR Level II.

Based on record review, staff and resident Interviews, and policy review the facility failed to provide 3 of 4 residents with their individualized Restorative Program as instructed by their Care Plans (Residents #11, #46, and #28). Facility reported census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #11 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive decline. The MDS revealed Resident #11 required extensive assistance of two or people with bed mobility, transfers, dressing, and toilet use. The MDS also documented diagnoses of Multiple Sclerosis (MS), reduced mobility, and muscle weakness. Record review of Resident #11, Care Plan on 12/21/23 lacked documentation of a restorative program for their right hand. Record review of three (3) untitled and undated documents 12/21/23 of Resident #11 does not receive routine restorative services. During and interview on 12/21/23 at 11:08 AM with Resident #11 revealed he does not receive routine restorative services, would like to three (3) times a week. Resident #11 stated he received restorative therapy three (3) times in the past month. He also informed he believed he was not receiving restorative therapy due to staffing issues 2. Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #28 required total staff assistance with bed mobility, toilet transfers, shower transfers, sit to stand, sit to lying, and roll left to right. The MDS indicated Resident #28 required a wheelchair for mobility. The MDS indicated Resident #28 had frequent pain in the last 5 days. Resident #28's MDS reflected active diagnoses of hypertension, renal insufficiency, renal failure, or end-stage renal disease (ESRD), and depression. In an interview on 12/21/23 at 09:30 AM, Resident #28 stated she was not participating in Restorative Therapy. She further stated she would like to participate if it was offered to her by the facility. Electronic Health Record (EHR) review of Resident #28's Care Plan indicated Restorative Therapy for when the resident is up in a wheelchair, in a recliner, and Active Range of Motion 2-6 times per week. In an interview with Staff B, Social Services Coordinator, on 12/21/23 at 09:46 AM revealed Resident #28 currently was not in Restorative Therapy. In a subsequent interview with Staff B, Social Services Coordinator, on 12/21/23 at 10:30 AM stated she spoke with Resident #28 and confirmed a request for Restorative Therapy. Review of the EHR Progress Notes dated 11/7/2023 at 04:05 PM by Social Services revealed a plan for Resident #28 to participate in Restorative Therapy. 49698 46873 3. The MDS dated [DATE] for Resident #46 documented she used a wheelchair and a walker as mobility devices and needed partial to moderate assistance with toilet use, dressing, transfers, and in the past three (3) days did not walk over 10 feet due to a medical condition or safety concerns. During an interview on 12/18/23 2:37 PM Resident # 46 revealed she was not getting her restorative program, she informed she wanted to get it but they don't have enough staff here to get it done. Record review of Resident #46 current Care Plan on 12/21/23 instructed she was to have a walking program daily and staff were to walk her with assist of one (1) with a walker and gait belt and to follow with the wheelchair as of 8/31/23 by the facilities MDS Coordinator. During an interview on 12/21/23 at 12:18 PM the MDS Coordinator revealed Resident #46 should be getting her restorative program and they are working on it. 41537 On 12/21/23 at 9:40 the Director of Nursing (DON) stated the MDS Coordinator is the restorative nurse. She stated they do not have a designated Restorative Aide. She said the Certified Nurse Aides (CNAs) do restorative as part of the daily routine. She stated her expectation is for the CNAs to document the amount of minutes of restorative that are done daily. She said for example, upper body range of motion should be done while assisting the resident to get dressed. On 12/21/23 at 9:53 am, Staff A, CNA stated she began employment in August of this year. She stated she knows the residents are supposed to get their Range of Motion and walking and get their exercising in for their restorative plans. She stated she was not aware she was supposed to be charting this and does not know how to chart restorative minutes. On 12/21/23 at 11:54 am, the MDS Coordinator stated the facility does not have a Restorative Aide. She stated the CNAs are to be documenting daily the activity or action minutes the resident participates in for their restorative program. She also stated she is supposed to be charting restorative notes monthly in the Progress Notes. She stated the most common restorative programs are range of motion and walking to dine which any of the aides can do and the Omni Cycle which the aides that are trained in restorative should perform. The policy Restorative Nursing Services, revision date July 2017, lacked instruction to staff on how to implement, provide, and document restorative programs.

Based on clinical record review, policy review and staff interview, the facility failed to provide services that met professional standards by not following physician's orders for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 67 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 3 which indicated severely impaired cognition. The MDS identified the resident had diagnoses which included non-Alzheimer's dementia and renal (kidney) insufficiency. The Care Plan dated 2/24/22 for Resident #2 revealed the resident had chosen Hospice care and directed staff to coordinate with the hospice team to assure she experienced as little pain as possible. During an interview 2/8/23 at 2:18 PM, the Director of Nursing (DON) reported she received a call from Hospice on 1/22/23 around 9:30 AM asking when the last time Resident #2 received morphine. The DON stated she looked in the Electronic Health Record (EHR) and there was an order for morphine to be given as needed every 2 hours and she had not given it yet. The DON stated the hospice nurse informed her an order was obtained yesterday for morphine to be scheduled and given every hour. The DON stated Staff B, Registered Nurse, had been notified by Hospice 1/21/22 of an order for morphine to be scheduled every hour. The DON further revealed Staff B thought since Hospice obtained the order they would enter the new order into the Electronic Health Record (EHR). The DON revealed she entered the order for morphine sulfate every hour into the EHR 1/22/23 at 9:38 AM and acknowledged the morphine every hour order had not been entered into the EHR and had not been given every hour as expected beginning 1/21/23. Review of facility policy titled, Medication and Treatment Orders, revised July 2016 documented verbal orders must be recorded immediately in the resident's Electronic Medical Record (EMR) by the person receiving the order. During an interview 2/8/28 at 2:55 PM, the DON reported the facility did not have a policy specific to receiving orders from hospice.

Based on clinical record review, policy review and staff interviews, the facility failed to ensure accurate transcription of Advanced Directives for 1 of 1 residents that experienced cardiac arrest (Resident #7). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had diagnoses which included pneumonia, respiratory failure and diabetes mellitus. The MDS documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition, and the resident required total dependence from staff for bed mobility and toileting. The Care Plan for Resident #7 dated [DATE] directed staff to honor her Advanced Directives. The Care Plan revised [DATE] directed staff to follow her code status declaration form. Review of facility form titled, Cardiopulmonary Resuscitation and DNR Order Declaration Form, was signed by Resident #7 on [DATE] requesting a do not resuscitate order from the physician. The form was signed by the resident's physician [DATE]. During an interview [DATE] at 1:15 PM, Staff A revealed she told Emergency Medical Services (EMS) Workers when they arrived at the facility that Resident #7 was a full code after she had checked the resident's code status in the Electronic Health Record (EHR) and required CPR after she had stopped breathing. Staff A further reported another EMS Worker came into the room after CPR had been initiated stating she thought the resident had been changed to DNR status during a recent hospitalization . Staff A stated she then contacted the Director of Nursing (DON) by phone and the DON confirmed the resident now had an order in place for DNR. Staff A notified the EMS workers of the DNR order and CPR stopped. Review of the Progress Notes for Resident #7 revealed a late entry completed at [DATE] at 3:19 AM by Staff A, Licensed Practical Nurse (LPN) documented Cardio pulmonary Resuscitation (CPR) was initiated on Resident #7 at 12:05 AM on [DATE]. The resident received Epinephrine injections x 2, fluids were initiated and a King Airway (mechanical ventilation) was inserted. Review of Progress Notes for Resident #7 revealed CPR stopped at 12:46 AM on [DATE] after it was confirmed by the DON the resident had a DNR order in place. Review of facility policy titled, Advanced Directives, revised [DATE] revealed information about whether or not the resident has executed an Advance Directive shall be housed in the Electronic Medical Record (EMR) and the Code Status Binder at the nurse's station. The policy further revealed the Director of Nursing Services or designee will notify the attending physician of Advanced Directive changes so the appropriate order can be obtained and documented in the EMR and an updated copy will be placed in the Code Status Binder at the nurse's station. During an interview [DATE] at 2:30 PM, the DON acknowledged the code status in the EHR for Resident #7 had stated she was a full code on [DATE] and the order in the Code Status Binder at the nurse's station had her as a DNR.

Based on facility policy review, clinical record review, and staff interviews, the facility failed to ensure the pre-admission screening and resident review (PASRR) was accurate upon admission for 1 (Resident #45) of 3 sampled residents reviewed for PASRR during the survey. The facility identified a census of 64 current residents. Findings include: Review of a facility policy titled, Admission Criteria, revised 03/2019, revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy also indicated, The facility conducts a Level 1 PASSAR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. Review of an undated Admission Record revealed Resident #45 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment, dated 04/22/2022, revealed Resident #45 was severely impaired in cognitive skills for daily decision-making and had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a, Notice of PASARR Level 1 Screen Outcome form, dated 04/08/2022, indicated Resident #45 did not require a level II PASARR due to no serious mental illness, intellectual disability, or related condition. Review of the Level I Form, dated 04/08/2022, revealed the resident had no mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment, dated 07/21/2022, revealed Resident #45 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 08/25/2022 at 11:00 AM, Staff A, the Social Services/Admission employee, stated she was responsible for reviewing resident PASARR upon admission and ensuring they were accurate. Staff A confirmed Resident #45's PASSAR was missing his mental health diagnoses. During an interview on 08/25/2022 at 2:27 PM, the Director of Nursing confirmed Admissions (Staff A) received resident PASARRs and reviewed them to ensure they were accurate. During an interview on 08/25/2022 at 2:47 PM, the Administrator stated that Admissions (Staff A) was to ensure the PASARRs were completed, and the Administrator expected them to be accurate.

Based on clinical record review, staff interviews, and facility investigation, the facility failed to take preventative measures to maintain separation of an alleged perpetrator from residents to ensure residents remained free from potential abuse. The facility also failed to complete a thorough investigation to ensure no abuse occurred prior to the alleged perpetrator being brought back to work. The failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. A concern was identified for Resident #1 who was tied with a sheet into her wheelchair. The alleged perpetrator returned to work without thorough investigation potentially exposing like residents to be restrained. The facility reported census was 59. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 10/28/21, Resident #1 had a Brief Interview for Mental Status score of 5 indicating a severely impaired cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included Non-Alzheimer's dementia, cerebrovascular accident (stroke) with aphasia and hemiplegia. Review of care plan notes Resident #1 is at risk for falls. There were no interventions addressing restlessness or using physical restraints. According to the facility's Dependent Adult Abuse Protocols: 1) Abuse includes the willful act to unreasonably confine a resident. 2) Mandatory Reporting Abuse Investigation Procedure includes: a) Allegations are to be reported immediately up the chain of command. b) The charge nurse shall separate the suspected abuser from the resident. c) The facility shall collect any supporting documentation relative to the incident. d) During the investigation, the facility shall suspend or terminate the accused staff. f) After the facility completes their investigation, the staff member accused may return to work if the nursing facilities investigation did not find founded abuse. e) If returned to the facility, continue to separate the staff member from the victim until there is no investigation determined or the department complete the investigation and is unfounded. According to Staff C's statement from 12/11/21, Staff C indicated that evening, Resident #1 was restless and not ready for bed, so they brought her back to the dining room and informed the nurses, Staff A and Staff B. Staff C stated she was in and out of the dining room and at one point saw Staff A and Staff B standing next to Resident #1, saying they were not going to get their work done and asking for a gait belt then a bed sheet. Staff C left the dining room for a few minutes and upon returning, witnessed both Staff A and Staff B at Resident #1's wheelchair with a bed sheet. Staff C could not see what they were doing, but after she left the area and returned a few minutes later, Resident #1 was observed in her wheelchair with a sheet crossed under her legs and tied to the chair arms, restraining her from getting up. Staff C immediately informed another CNA who contacted the DON and initiated an investigation. The CNA was instructed to untie the sheet and then took Resident #1 to room and the resident was no longer restless and was assisted to bed. According to Staff P's statement from 12/12/2022, Staff P indicated after Staff C reported that the nurses had taken a bed sheet and tied the resident to wheelchair in the dining room. Staff P went and observed Resident #1 and could see the resident struggling against the white bed sheet that wrapped around chest and it was also wrapped legs. Staff C and Staff were instructed to untie the resident. Staff C struggled to untie the bed sheet especially how it was woven around the resident. According to Staff A's statement from 12/12/21, Staff A indicated Resident #1 had been agitated and restless that evening and they placed a sheet over her to provide comfort. When informed the bed sheet was tied to the chair arms, Staff A did not confirm or deny she was involved with tying the bed sheet. On 12/15/21 when asked if she was involved with restraining Resident #1, Staff A stated I helped with getting a blanket on her, but I didn't tie it on. When asked why they were doing this, Staff A stated it was to keep her from sliding out of her chair. Even with the dycem and one way glide, she was still sliding out of the chair. According to Staff B's statement from 12/11/21, Staff B indicated she was involved with putting a sheet over Resident #1 because she had been disrobing and the sheet may have gotten tangled up because she had been restless and moving a lot. On 12/12/21 Staff B was informed of being suspended and responded by saying her hands were not restrained. When told the sheet had been tied to the wheelchair arms, Staff B did not respond to this but asked if she would be able to come back to finish her scheduled shifts. Observation of a photo taken at the time Resident #1 was tied in the wheelchair showed a bed sheet wrapped between the resident's legs and around the legs. The the ends of the bed sheet was tied to the back rest of the wheelchair. In an interview on 5/23/22 at 3:55 p.m. the Director of Nursing (DON) stated on the evening of 12/11/21 she received a call informing her there was an allegation of abuse involving Resident #1. The DON was informed witnesses saw Resident #1 restrained in her wheelchair with a bed sheet. The DON initiated an investigation and spoke with those present that evening. During the course of her investigation, two nurses, Staff A and Staff B, were identified as the alleged perpetrators. The two nurses were suspended pending the outcome of the facility investigation. Both Staff A and Staff B admitted to placing the bed sheet over Resident #1 and both Staff A and Staff B denied tying the bed sheet to the wheelchair. The DON stated following her investigation, she concluded Resident #1 had been restrained in her wheelchair with a bed sheet tied to the wheelchair arms and that it was abuse, however was hesitant to identify whether it was Staff A, Staff B or both involved as the perpetrator. The DON stated the investigation was discussed with their corporate management team and the team determined Staff A could return to work under conditions which provided better supervision. Staff B was an agency nurse and her contract was up and not renewed. In an interview on 5/24/22 at 2:50 p.m. The Administrator stated on 12/11/21 she was contacted by her DON and informed of an allegation of abuse involving Resident #1 and two nurses. It was alleged that Resident #1 had been restrained in her wheelchair using a bed sheet. The DON interviewed staff present that evening and upon finishing the interviews, she discussed the incident with their Human Resource management team. It was determined Staff A could return to work with conditions and Staff B was believed to be the perpetrator. The Administrator was asked what evidence they had to support that conclusion and she responded Staff A was not cruel and was suitable to return to work. The Administrator was asked if a bed sheet was used to restrain a resident in her wheelchair for the convenience of staff, would she consider that abuse. The Administrator stated yes. The Administrator was asked if she was aware of a picture taken by a witness that evening, showing the resident restrained in her wheelchair. The Administrator stated she was aware Staff C had taken a picture, but had not seen it. Staff C was instructed to delete the photo. The Administrator stated she did not keep the photo as evidence. According to the facilities investigative summary, an allegation that Resident #1 was restrained in her wheelchair with a bed sheet was made on the evening of 12/11/21 at 8:45 p.m. The DON contacted the facility to ensure Resident #1 was not restrained. She spoke with Staff A, who acted unaware of whether Resident #1 was restrained or not. Then Staff B called the DON stating Resident #1 had not been restrained. Staff B stated Resident #1 had been restless and disrobing and a sheet was placed over her for this reason. The following day additional statements were collected. Staff C stated she had been the one who noticed Resident #1 restrained with a bed sheet and untied the sheet from the wheelchair. The DON had Staff A and Staff B suspended pending the investigation. The summary indicated both Staff A and Staff B would be reeducated regarding care and treatment of residents. Written offense were added to the Staff A and Staff B employment file. Reeducation for all staff regarding the use of restraints and what constitutes a restraint. The summary implies Staff A and Staff B are suspected perpetrators, but does not provide a conclusion to their investigation. According to an email addressed to the facility Administrator from the Regional Director of Human Resources dated 12/16/21, it was determined Staff A would be removed from suspension under the following conditions: *Staff A will move to day shifts where she will receive more supervision. *Staff A will not work in the memory care unit at this time until approved by the Administrator. *Additional Relias courses on resident abuse will be assigned to Staff A to be completed by 1/4/22. *EAP will be highly encouraged. *The Administrator and Regional Director of HR will have weekly conversations with Staff A. *The Administrator and DON will visually check on Staff A throughout her shift for 30 days. *The Administrator will check with residents in Staff A's care twice weekly for 30 days. The State Agency notified the facility of the Immediate Jeopardy on 5/25/22 at 3:25 p.m. The Immediate Jeopardy situation started on 12/17/21. The facility removed the Immediate Jeopardy on 5/25/22 by: Staff A was immediately suspended effective 5/25/22 Staff education will be provided regarding expectation of separation and reporting following any allegation or observation of any form of abuse Monitoring. Staff Education will be provided regarding investigation expectations. Staff education will be provided regarding the definition of a restraint Staff Education will be provided regarding the definition of abuse and neglect. Notification added to facility bulletin board stating the expectation regarding separation and reporting following any allegation or observation of any form of abuse. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education.

Based on clinical record review, staff interviews, and facility investigation review, the facility failed to ensure residents were kept free from physical restraint imposed for the purpose of convenience for 1 of 5 current residents reviewed (Resident #1). The facility reported a census of 59. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with a reference date of 10/28/21, Resident #1 had a Brief Interview for Mental Status score of 5 indicating a severely impaired cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included Non-Alzheimer's dementia, cerebrovascular accident (stroke) with aphasia and hemiplegia. Review of Resident #1's care plan revealed Resident #1 as at risk for falls, initiated 4/5/19. The care plan contained no interventions addressing restlessness or the use of physical restraints. According to a stated provided by Staff C, certified nursing assistant (CNA), dated 12/11/21, Staff C indicated that evening, Resident #1 was restless and not ready for bed, so they brought her back to the dining room and informed the nurses, Staff A and Staff B. Staff C stated she was in and out of the dining room and at one point saw Staff A and Staff B standing next to Resident #1, saying they were not going to get their work done and asking for a gait belt then a bed sheet. Staff C left the dining room for a few minutes and upon returning, witnessed both Staff A and Staff B at Resident #1's wheelchair with a bed sheet. Staff C could not see what they were doing, but after she left the area and returned a few minutes later, Resident #1 was in her wheelchair with a sheet crossed under her legs and tied to the chair arms, restraining her from getting up. Staff C immediately informed another CNA who contacted the Director of Nursing (DON) and initiated an investigation. According to a statement provided by Staff A, licensed practical nurse (LPN) dated 12/12/21, Staff A indicated Resident #1 had been agitated and restless that evening and they placed a sheet over her to provide comfort. When informed the bed sheet was tied to the chair arms, Staff A did not confirm or deny her involvement with tying the bed sheet. On 12/15/21 when asked if she was involved with restraining Resident #1, Staff A stated she helped getting a blanket on the resident, but didn't tie it on. When asked why they were doing this, Staff A stated it was to keep the resident from sliding out of her chair. Even with the Dycem (an anti-slip pad) and one way glide, she was still sliding out of the chair. According to Staff B's statement from 12/11/21, Staff B recorded she was involved with putting a sheet over Resident #1 because she had been disrobing and the sheet may have gotten tangled up because the resident had been restless and moving a lot. On 12/12/21 Staff B was informed of being suspended and responded by saying the resident's hands were not restrained. When told the sheet had been tied to the wheelchair arms, Staff B did not respond to this but asked if she would be able to come back to finish her scheduled shifts. In an interview on 5/23/22 at 3:55 p.m. the DON stated on the evening of 12/11/21 she received a call informing her there was an allegation of abuse involving Resident #1. The abuse consisted of Resident #1 being restrained to her wheelchair with a bed sheet. During the course of her investigation, 2 nurses, Staff A and Staff B, were identified as the alleged perpetrators. Both Staff A and Staff B admitted to placing the bed sheet over Resident #1 and both Staff A and Staff B denied tying the bed sheet to the wheelchair. Nevertheless, the DON concluded Resident #1 had been restrained in her wheelchair with a bed sheet tied to the wheelchair arms and that it was abuse. However the DON was hesitant to identify whether it was Staff A, Staff B or both involved as the perpetrator. In an interview on 5/24/22 at 2:50 p.m. the Administrator stated on 12/11/21 she was contacted by her DON and informed of an allegation of abuse involving Resident #1 and 2 nurses. It was alleged that Resident #1 had been restrained in her wheelchair using a bed sheet. The Administrator reviewed the facility's investigation with their Human Resource management team and determined Staff B as the perpetrator.

Based on facility record review and staff interview, the facility failed to ensure every nurse aide receives, at minimum, 12 hours of in-service education annually for 3 of 10 nurse aide records reviewed (Staff D, Staff M and Staff O). The facility reported census was 59. Findings include: Review of 10 nurse aide training records found 3 with less than the minimum 12 hours required (Staff D, Staff M and Staff O). In an interview on 6/1/22 at 11 AM, the Administrator stated they use an on-line training system for their staff. The Administrator stated they were unable to find any additional in-service education for the 3 nurse aides identified with inadequate training.

Based on clinical record review, staff interviews, and facility investigation, the facility failed to take preventative measures to maintain separation of an alleged perpetrator from residents to ensure residents remained free from potential abuse. The facility also failed to complete a thorough investigation to ensure no abuse occurred prior to the alleged perpetrator being brought back to work. The failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. A concern was identified for Resident #1 who was tied with a sheet into her wheelchair. The alleged perpetrator returned to work without thorough investigation potentially exposing like residents to be restrained. The facility reported census was 59. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 10/28/21, Resident #1 had a Brief Interview for Mental Status score of 5 indicating a severely impaired cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan notes Resident #1 is at risk for falls. There were no interventions addressing restlessness or using physical restraints. According to the facility's Dependent Adult Abuse Protocols: 1) Abuse includes the willful act to unreasonably confine a resident. 2) Mandatory Reporting Abuse Investigation Procedure includes: a) Allegations are to be reported immediately up the chain of command. b) The charge nurse shall separate the suspected abuser from the resident. c) The facility shall collect any supporting documentation relative to the incident. d) During the investigation, the facility shall suspend or terminate the accused staff. f) After the facility completes their investigation, the staff member accused may return to work if the nursing facilities investigation did not find founded abuse. e) If returned to the facility, continue to separate the staff member from the victim until there is no investigation determined or the department complete the investigation and is unfounded. According to Staff C's statement from 12/11/21, Staff C indicated that evening, Resident #1 was restless and not ready for bed, so they brought her back to the dining room and informed the nurses, Staff A and Staff B. Staff C stated she was in and out of the dining room and at one point saw Staff A and Staff B standing next to Resident #1, saying they were not going to get their work done and asking for a gait belt then a bed sheet. Staff C left the dining room for a few minutes and upon returning, witnessed both Staff A and Staff B at Resident #1's wheelchair with a bed sheet. Staff C could not see what they were doing, but after she left the area and returned a few minutes later, Resident #1 was observed in her wheelchair with a sheet crossed under her legs and tied to the chair arms, restraining her from getting up. Staff C immediately informed another CNA who contacted the DON and initiated an investigation. The CNA was instructed to untie the sheet and then took Resident #1 to room and the resident was no longer restless and was assisted to bed. According to Staff P's statement from 12/12/2022, Staff P indicated after Staff C reported that the nurses had taken a bed sheet and tied the resident to wheelchair in the dining room. Staff P went and observed Resident #1 and could see the resident struggling against the white bed sheet that wrapped around chest and it was also wrapped legs. Staff C and Staff were instructed to untie the resident. Staff C struggled to untie the bed sheet especially how it was woven around the resident. According to Staff A's statement from 12/12/21, Staff A indicated Resident #1 had been agitated and restless that evening and they placed a sheet over her to provide comfort. When informed the bed sheet was tied to the chair arms, Staff A did not confirm or deny she was involved with tying the bed sheet. On 12/15/21 when asked if she was involved with restraining Resident #1, Staff A stated I helped with getting a blanket on her, but I didn't tie it on. When asked why they were doing this, Staff A stated it was to keep her from sliding out of her chair. Even with the dycem and one way glide, she was still sliding out of the chair. According to Staff B's statement from 12/11/21, Staff B indicated she was involved with putting a sheet over Resident #1 because she had been disrobing and the sheet may have gotten tangled up because she had been restless and moving a lot. On 12/12/21 Staff B was informed of being suspended and responded by saying her hands were not restrained. When told the sheet had been tied to the wheelchair arms, Staff B did not respond to this but asked if she would be able to come back to finish her scheduled shifts. Observation of a photo taken at the time Resident #1 was tied in the wheelchair showed a bed sheet wrapped between the resident's legs and around the legs. The the ends of the bed sheet was tied to the back rest of the wheelchair. In an interview on 5/23/22 at 3:55 p.m. the Director of Nursing (DON) stated on the evening of 12/11/21 she received a call informing her there was an allegation of abuse involving Resident #1. The DON was informed witnesses saw Resident #1 restrained in her wheelchair with a bed sheet. The DON initiated an investigation and spoke with those present that evening. During the course of her investigation, two nurses, Staff A and Staff B, were identified as the alleged perpetrators. The two nurses were suspended pending the outcome of the facility investigation. Both Staff A and Staff B admitted to placing the bed sheet over Resident #1 and both Staff A and Staff B denied tying the bed sheet to the wheelchair. The DON stated following her investigation, she concluded Resident #1 had been restrained in her wheelchair with a bed sheet tied to the wheelchair arms and that it was abuse, however was hesitant to identify whether it was Staff A, Staff B or both involved as the perpetrator. The DON stated the investigation was discussed with their corporate management team and the team determined Staff A could return to work under conditions which provided better supervision. Staff B was an agency nurse and her contract was up and not renewed. In an interview on 5/24/22 at 2:50 p.m. The Administrator stated on 12/11/21 she was contacted by her DON and informed of an allegation of abuse involving Resident #1 and two nurses. It was alleged that Resident #1 had been restrained in her wheelchair using a bed sheet. The DON interviewed staff present that evening and upon finishing the interviews, she discussed the incident with their Human Resource management team. It was determined Staff A could return to work with conditions and Staff B was believed to be the perpetrator. The Administrator was asked what evidence they had to support that conclusion and she responded Staff A was not cruel and was suitable to return to work. The Administrator was asked if a bed sheet was used to restrain a resident in her wheelchair for the convenience of staff, would she consider that abuse. The Administrator stated yes. The Administrator was asked if she was aware of a picture taken by a witness that evening, showing the resident restrained in her wheelchair. The Administrator stated she was aware Staff C had taken a picture, but had not seen it. Staff C was instructed to delete the photo. The Administrator stated she did not keep the photo as evidence. According to the facilities investigative summary, an allegation that Resident #1 was restrained in her wheelchair with a bed sheet was made on the evening of 12/11/21 at 8:45 p.m. The DON contacted the facility to ensure Resident #1 was not restrained. She spoke with Staff A, who acted unaware of whether Resident #1 was restrained or not. Then Staff B called the DON stating Resident #1 had not been restrained. Staff B stated Resident #1 had been restless and disrobing and a sheet was placed over her for this reason. The following day additional statements were collected. Staff C stated she had been the one who noticed Resident #1 restrained with a bed sheet and untied the sheet from the wheelchair. The DON had Staff A and Staff B suspended pending the investigation. The summary indicated both Staff A and Staff B would be reeducated regarding care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Reeducation for all staff regarding the use of restraints and what constitutes a restraint. The summary implies Staff A and Staff B are suspected perpetrators, but does not provide a conclusion to their investigation. According to an email addressed to the facility Administrator from the Regional Director of Human Resources dated 12/16/21, it was determined Staff A would be removed from suspension under the following conditions: *Staff A will move to day shifts where she will receive more supervision. *Staff A will not work in the memory care unit at this time until approved by the Administrator. *Additional Relias courses on resident abuse will be assigned to Staff A to be completed by 1/4/22. *EAP will be highly encouraged. *The Administrator and Regional Director of HR will have weekly conversations with Staff A. *The Administrator and DON will visually check on Staff A throughout her shift for 30 days. *The Administrator will check with residents in Staff A's care twice weekly for 30 days. The State Agency notified the facility of the Immediate Jeopardy on 5/25/22 at 3:25 p.m. The Immediate Jeopardy situation started on 12/17/21. The facility removed the Immediate Jeopardy on 5/25/22 by: Staff A was immediately suspended effective 5/25/22 Staff education will be provided regarding expectation of separation and reporting following any allegation or observation of any form of abuse Monitoring. Staff Education will be provided regarding investigation expectations. Staff education will be provided regarding the definition of a restraint Staff Education will be provided regarding the definition of abuse and neglect. Notification added to facility bulletin board stating the expectation regarding separation and reporting following any allegation or observation of any form of abuse. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education.

Based on record review and staff interviews, the facility failed to provide adequate supervision of a resident who was at high risk for falls and who was getting up frequently unassisted while in the dining room and failed to properly supervise residents who were physically aggressive towards other residents for 3 of 4 incidents reviewed. (Residents #2, #6, #9, #4, #5) The facility reported census was 59. Findings include: 1. According to Resident #6's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #6 had a brief interview for mental status (BIMS) score of 5 indicating a severely impaired cognitive status. Resident #6 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #6's diagnosis included Alzheimer's, Non Alzheimer's dementia, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Resident #6's plan of care indicated a focus area on risk for falls with interventions which included making sure Resident #6 was wearing proper footwear, provided a safe environment without clutter, provided grippy strips at bedside and in front of recliner, provided dycem for her recliner wheelchair and place a black mat at bedside to decrease risk for injury. According to incident reports from [DATE] through [DATE], Resident #6 had 17 recorded falls. 5 falls occurred in November alone. The incident report dated [DATE] at 4:20 p.m. indicated it was near dinner time and the dining room was noisy with several visitors entering the building and using the doorbell. Resident #6 had got up unassisted on several occasions to answer the doorbell and was redirected back to her chair each time. At 4:20 p.m. Resident #6 was discovered on the floor. Resident #6 had a hematoma above her right eye and her left hip appeared out of socket. Resident #6 screamed in pain when touched. The physician was notified and Resident #6 was sent out to the emergency room for evaluation. According to the emergency room Note: assessment dated [DATE], Resident #6 sustained an acute fracture of the pubic ramus (pelvis) and was also diagnosed with pulmonary [CONDITION(S)], possible bacterial pneumonia, end stage Alzheimer's disease and end stage lung disease. The family decision was made for Resident #6 to return to the facility with a focus on comfort care. The emergency room physician did not expect Resident #6 to thrive much longer at the care center given this new fracture. Resident #6 eventually expired on [DATE]. In an interview on [DATE] at 12:13 p.m. Staff L, licensed practical nurse, stated on [DATE] she was at the nurse's station when Resident #6 stood up unassisted in the dining room and fell . Staff L stated one moment Resident #6 was sitting and when she turned around she was on the floor. Staff L stated Resident #6 had been up unassisted multiple times answering the door bell, which was near her table. Staff L stated she was uncertain where the aides were at the time of the fall, noting they only had ,d+[DATE] aides that evening. Staff L stated Resident #6 probably needed a 1:1. but there was not enough staff and other residents care and supervision would have suffered. In an interview on [DATE] at 1:07 p.m. Staff M, certified nurse aide, stated she usually does not work beyond 2:00 p.m., but on [DATE] she must have, because she recalls walking down hall three towards the dining room and coming upon Resident #6, who had just fallen. Staff M stated there were only three aides working which is usual, but not adequate to meet resident needs, noting it takes at least four. In an interview on [DATE] at 12:55 p.m. Staff N, certified nurse aide, stated on the afternoon of [DATE] she recalled walking down hall 4 towards the dining room when Resident #6 had fallen. Staff N stated there were only three aides working that evening. Staff N stated she was assigned hall 4 and Resident 6 was not on that hall. _______________________________________________________________________________________ 2. According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #2 had a brief interview for mental status (BIMS) score of 4 indicating a severely impaired cognitive status. Resident #2 was independent with bed mobility and transfers and required limited assistance with dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included Alzheimer's and Non Alzheimer's dementia and she resided on a memory care unit. Resident #2's plan of care indicates a focus area of impaired cognitive function/dementia or impaired thought process related to dementia, noting Resident #2 may strike out at staff, use profanity and on [DATE] and [DATE] was hit in the face by Resident #9. Interventions [DATE] included keep Resident #2 and Resident #9 separated. According to Resident #9's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #9 had a brief interview for mental status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #9 was independent with bed mobility and transfers and required minimal assistance with dressing, toilet use and personal hygiene needs. Resident #9's diagnosis included Alzheimer's and Non Alzheimer's dementia and he resided on a memory care unit. Resident #9's plan of care indicates a focus area of impaired cognitive function related to Alzheimer's disease noting Resident #9 has struck Resident #2 in the face on [DATE], [DATE] and [DATE]. Interventions [DATE] included keep Resident #2 and Resident #9 separated and Resident #9 has sundowning and seems more restless and agitated and may need someone to walk with him. In an interview on [DATE] at 1:56 p.m. Staff H, certified nurse aide, stated on [DATE], she was working on the memory care unit. Staff H states she was sitting at a table next to Resident #2, who was rambling. Resident #9 approached Resident #2, told her to shut up and immediately slapped her across the face. Staff H stated she separated the residents and informed the nurse. Staff H stated she was unaware of the history between the two residents or of the care plan intervention to keep them separated from one another. ______________________________________________________________________________________ 3. According to Resident #4's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #4 had a brief interview for mental status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #4 was independent with bed mobility and transfers, required limited assistance with dressing and extensive assistance with toilet use and personal hygiene needs. Resident #4's diagnosis included Alzheimer's and Non Alzheimer's dementia and he resided on a memory care unit. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #5 had a brief interview for mental status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #5 required limited assistance with bed mobility, transfers and dressing and required extensive assistance with toilet use and personal hygiene needs. Resident #5's diagnosis included Alzheimer's and Non Alzheimer's dementia and she resided on a memory care unit. Resident #5's plan of care indicates a focus area on potential for physical aggression related to dementia with an intervention including when Resident #5 is agitated with another resident, intervene and redirect resident to another activity. In an interview on [DATE] at 12:10 p.m. Staff I, certified nurse aide, stated she and another aide were working on the memory care unit on [DATE]. Resident #5 had just returned after being out with family for a week. At 4:10 p.m. Resident #4 was standing in the hallway near the dining room, when without notice, Resident #5 approached him and struck him in his abdomen. Staff I immediately separated the two residents, sending Resident #5 back to her room and Resident #4 to a chair near his room. Staff I stated she reported the incident to the charge nurse. A few minutes later, at 4:18 p.m., Resident #5 ambulated out of her room with her wheel walker and rammed the walker into Resident #4. Staff I stated she was standing next to Resident #4 at the time. The residents were again separated and Resident #4 was moved to a chair closer to the dining room. Resident #5 returned to her room. Minutes later at 4:25 p.m. Resident #5 returned to the hallway and as Resident #4 stood, Resident #5 struck Resident #4's arm. Residents were separated and the nurse notified. At that time they added an intervention for staff to remain with Resident #4 when in the dining room and to keep Resident #4 away from Resident #5 and for staff to provide stand by supervision of Resident #5 when she is in the dining room. Staff I stated there were no further incidents that afternoon.

Based on staff interviews and record review, the facility failed to ensure residents remained free from abuse for 2 of 4 sampled (Residents #1, and #2). Resident #1 and Resident #2 were spoken to by a Nurse Aide in a humiliating and intimidating manner which upset both residents emotionally. The facility reported a census of 66. Findings include: 1. According to Resident #1's Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had short and long term memory deficits and severely impaired cognitive abilities for daily decision making. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 had [DIAGNOSES REDACTED]. During an interview on 3/1/20 at 9:38 a.m. Staff A (Nurse Aide Trainee) stated she shadowed Staff B and Staff C on the 2:00 p.m. to 10:00 p.m. shift on [DATE]. Staff A, Staff B, and Staff C assisted Resident #1 in her room. Resident #1 had unopened birthday cards. Staff C opened the cards and read them. Staff C stated in the presence of Resident #1, I'm surprised they wrote you, because they don't f****** visit you. Staff B stated, You can't say that. Staff C stated, Well, it's true. Staff C stated to Resident #1, We don't like you, you're mean to us. Staff A stated Resident #1 did not respond to Staff C's comments. The staff finished Resident #1's cares and left the room. During an interview on 2/26/20 at 2:00 p.m., Staff B (Nurse Aide) stated she had Staff A shadowing her. Staff A and Staff B entered Resident #1's room after supper. Staff C already in the room, read Resident 1's birthday cards to her. Staff C comment about the family not visiting and Staff B stated she told Staff C not to make comments in front of the resident. Staff B stated Staff C did not swear or use profanity, but spoke negatively about the family not visiting. Staff B was informed that Staff A claimed Staff C said I'm surprised they wrote you because they don't f****** visit you and We don't like you, you are mean to us. Staff B stated she was in the room the entire time and Staff C never said anything like that. Staff B stated both she and Staff A left the room at the same time. 2. According to Resident #2's MDS assessment dated [DATE] Resident #2 had a Brief Interview for Mental Status score of 6 indicating severely impaired cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's had [DIAGNOSES REDACTED]. During an interview on 3/1/20 at 9:38 a.m., Staff A (Nurse Aide Trainee) reported following the incident with Resident #1, Staff A and Staff C entered Resident #2's room. Staff B not present. Staff C assisted Resident #2 onto the toilet. Resident #2 cried and stated, I'm sorry, I know I'm mean to you and they don't like me. Staff C stated in the presence of Resident #2, You're right, we [***] ing hate you, you should just die. Resident #2 responded, I know, I want to die. Staff C closed the bathroom door and sat in Resident #2's wheelchair and got on her cell phone. Resident #2 continued to cry and stated she was done and wanted up. Staff C yelled through the closed door, Shut up, you're not done[***]ing because I can still hear you. Resident #2 then turned on her call light and Staff C shut it back off. Finally when Resident #2 seemed finished, Staff C paged Staff B who responded and assisted with wiping and cleaning Resident #2's bottom, while Staff C again stated out load and in the presence of Resident #2, Don't[***]on Staff B. They finished, got Resident #2 into bed and left the room. Staff A stated Resident #2 was upset and crying during the entire interactions with staff. Staff A stated she did not know what to do until she completed the Dependent Adult Abuse for Mandatory Reporter training on 12/8/19. Staff A reported the incident the next day she returned to work on 12/12/19. During an interview on 2/26/20 at 2:00 p.m. Staff B (Nurse Aide) reported she had Hall 3 with Staff A (Nurse Aide Trainee). Staff B stated following the encounter with Resident #1 another incident occurred. Resident #2 used the toilet and started to stand up and decided still needed to use the toilet. Staff B told Resident #2 she needed to sit down and Resident #2 started crying, which was not unusual for her. Staff C stated something like you will not be[***]ing on my aide. Staff B stated she felt uncomfortable with the comment and started to leave the room. Staff B reported she stood outside Resident #2's room with Staff A. Staff B decided to return to the room to help Resident #2. Staff B stated no further inappropriate comments were made. Staff B stated she left the room at the same time as Staff A. Staff B learned Staff A claimed Staff C stated to Resident #2, We f****** hate you, you should just die, you're not done yet, you've[***]on my aide for the last time, Shut up, you're not done[***]ing because I can still hear you and Don't[***]on her (Staff B). Staff B reported the only inappropriate comment by Staff C had something to the effect of you will not be[***]ing on my aide. Staff B stated the other alleged comments were false. Staff B stated she was in the room the entire time and left with Staff A. Staff B reported they had two aides and a trainee for three halls. The staff were frustrated and on edge. During an interview on 2/27/20 at 4:10 p.m. the Administrator reported all staff completed the Dependent Adult Abuse for Mandatory Reporters training after Staff A and Staff B failed to report the two allegations. All staff completed the training by 12/31/19. The Administrator suspended Staff C on 12/12/19 and terminated on [DATE] for verbal abuse. The Administrator suspended Staff B on 12/12/19 pending the investigation. Staff B received a written disciplinary action on [DATE] for failing to report verbal abuse. Staff B resigned after the disciplinary action. Staff A resigned after reporting the verbal abuse on 12/12/19.

Based on record review and staff interviews, the facility failed to provide adequate supervision in order to ensure residents in the CCDI (Chronic Confusion or a Dementing Illness), are free from fear and physical abuse from Resident #1. The sample consisted of 7 residents and the facility reported a census of 68 residents and 11 of the 68 residents resided in the CCDI secured unit. Findings include: 1. According to the Face Sheet Resident #1, had [DIAGNOSES REDACTED]. Resident #1 had a MDS assessment with a reference date of 4/12/16. The MDS identified the resident had a Brief Interview for Mental Status (BIMS) score of 3. A score of 3 indicated the resident had a severe cognitive impairment. The MDS indicated the resident required supervision with bed mobility, transfers and ambulation, and documented the resident had physical behaviors toward others occurring 1 to 3 days of the assessment period. The Care Plan dated 4/15/16 identified the resident had behaviors of striking another resident. The Care Plan approach included and directed the staff to redirect the resident away from arm ' s length contact with 3 other female residents and reinforce unacceptability of the resident's verbal abuse. The Care Plan identified the resident lived in the CCDI unit for a safe and secure environment. An Incident/Accident/Unusual Occurrence form dated 2/11/16 at 4:00 p.m. indicated Resident #1 sat at the dining room table. Another resident approached the table and Resident #1 reached over with the left hand and pushed the other resident (Resident #5) on the right hip. The resident did not lose her/his balance but did make a noise. Resident #1 did not seem to be in pain. The Incident/Accident/Unusual Occurrence form dated 4/2/16 at 12:50 p.m. indicated Resident #1 struck another resident (Resident #5) on the back of the head when in the dining room. The Incident/Accident/Unusual Occurrence form dated 4/15/16 at 8:00 a.m. indicated Resident #1 sat at the dining room table with another Resident (Resident #6). A visitor witnessed Resident #1 walk over to Resident #6 and slapped the resident on the back of the head. The visitor stepped between the two residents to separate them. Resident #1 informed Resident #6, she/he needed to move because this was not where Resident #6 sat in the dining room. The staff moved a long rectangle table into the space where the 2 round tables were to help Resident #1 feel protected of space and make this more homelike. On 4/17/16 at 6:30 a.m., Resident #1 sat in the main dining room at a table. Resident #1 became agitated when another resident (Resident #7) yelled out and screaming. Resident #1 struck the resident on the upper right arm. Resident #7 had no known injury. The Incident/Accident/Unusual Occurrence form dated 4/25/16 at 6:30 a.m. indicated Resident #7 sitting at the dining room table and yelling out per usual. Resident #1 became agitated and upset and thought he/she was being yelled at. Resident #1 struck Resident #7 in the right upper arm with foam tubing from the edge of the table. In an interview on 7/11/16 at 2:00 p.m., the Director of Nursing (DON) stated Resident #1 has a history of resident to resident physical incidents. In an interview on 7/11/16 at 4:13 p.m., Staff A stated Resident #1 wanders a lot at night, and has a history of behaviors. In an interview on 7/11/16 at 4:17 p.m., Staff C, Licensed Practical Nurse (LPN), stated staff that work in the unit are fearful of Resident #1. Staff C stated the resident has threatened staff, exits seeks and has a history of striking out at other residents.

Based on clinical record review and interviews with resident and staff, the facility failed to ensure Resident #1 received transfer assistance and adequate supervision from hazards in the environment for one (1) of four (4) residents reviewed. Resident #1 reported a staff person let go of his/her gait belt during a transfer when he/she sustained an injury. Staff interview revealed Resident #1 required staff assistance during transfers to maintain his/her safety. The staff reported she let go of Resident #1's gait belt to open the bathroom door (which was approximately 7 feet away) and after the resident fell backwards on the toilet, she left the resident alone in the room to obtain the nurse. Record review identified the resident sustained [REDACTED].The facility reported a census of 66 residents. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 7/30/13, Resident #1 has a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairments for daily decision making skills. Resident #1 required one staff person to physically assist him/her with bed mobility, dressing, bathing, toilet assistance, personal hygiene needs and with transfers. The functional status for toileting assistances related to how the resident used the toilet room or commode; or transfers on/off the toilet. The MDS explained the functional status for transfers related to how the resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet). The resident's balance during transition and walking identified the resident was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking (with the assistive device if used); when turning around, when moving on and off the toilet and during surface to surface transfer. Resident #1's [DIAGNOSES REDACTED]. The incident/accident form dated 9/7/13 documented the aide stated she let go of Resident #1 to open the (bathroom) door and the resident fell back onto the toilet. The report document the resident complained of hip pain and had been transferred to the emergency room . The report noted the resident's 4 wheel walker had been used. The resident's care plan with a goal date 5/5/2013 documented the resident used a FWW (front wheel walker) and the assist of one staff. Radiology report dated 9/7/13 indicates a CT scan of pelvis finds a comminuted, minimally displaced left acetabular fracture with medial left pelvic hematoma. The report document given positioning of the left femoral head, this fracture was likely an impaction fracture in nature. In an interview with Resident #1 on 9/23/13 at 4:50 p.m., the resident stated he/she was being assisted off the toilet and the staff stood him/her up and then left him/her to open the door. Resident #1 reported he/she was unable to stand and told the aide he/she was falling, but the aide left him/her anyway. The resident indicated the same aide had done this before, but a nurse had been there to help him/her. Resident #1 indicated he/she had been wearing the belt (gait belt) when the incident occurred. In an interview on 9/24/13 at 1:05 p.m. Staff A, certified nurse aide (CNA), indicated she was assisting Resident #1 off the toilet in the hall 3 shower room. Staff A reported when the resident was finished, she stood him/her up, using the gait belt and cleaned the resident up. Staff A reported she pulled the resident's pants up. Staff A reported the resident was holding on to his/her walker, standing in front of the toilet. Staff A reported she was on the resident's right side and went to switch over to his/her left side so she could open the door. (The facility determined the door measured approximately 7 feet away from the toilet.) As Staff A stated she was reaching for the door and let go of the resident's gait belt. Staff A reported she was in arms reach of the resident and then the resident fell on to the toilet. Staff A reported she then went to ask the resident if he/she was ok. The resident did not give her a straight answer so she left the room to get a nurse (leaving the resident again). Staff A reported Resident #1 was the assist of one staff at the time (of the incident). Staff A stated Resident #1 needed the assistance of one staff with transfers and ambulation and she knew she was supposed to maintain contact with the gait belt at all times. In an interview on 9/23/13 at 6:15 p.m. Staff B, Licensed Practical Nurse, stated she had been summoned to the hall 3 shower room by Staff A. Upon entering the room, Resident #1 had been sitting on the toilet. Staff B noticed a skin tear to Resident #1's right forearm and Resident #1 was complaining of left hip pain. Resident #1 refused range of motion to left extremity. Resident #1 was transferred with assist of two staff into a wheel chair. Resident #1's physician was notified the resident had been sent to the local hospital for an evaluation. Staff B revealed she was informed by Staff A that while transferring, Staff A let go of the gait belt to switch sides and Resident #1 fell back onto the toilet. Staff B stated the gait belt was around Resident #1's waist when she entered the room. In an interview on 9/24/13 at 12:04 p.m. the Director of Nursing (DON) stated the expectation of gait belt use was that staff maintained contact with the gait belt when transferring a resident or ambulating. The DON revealed Staff A received disciplinary action for not maintaining physical contact with the gait belt during the transfer of Resident #1. In an interview on 9/24/13 at 12:18 p.m. the Assistant Director of Nursing (ADON) reported staff are expected to use a gait belt whenever a resident required assistance with transfers or during ambulation. Staff are expected to know how to properly place the gait belt and to always maintain contact with the gait belt during the transfer or when walking with a resident. The Department contacted the nursing home staff and asked for additional information. The Administrator reported on 10/7/13 via email, when the incident occurred on 9/7/13, Staff A was standing between the toilet and the sink on the resident's right side. Staff A put the gait belt on the resident and stood him/her up holding on to the gait belt. As soon as the resident was standing, Staff A went to switch to the resident's left side in preparation of opening the bathroom door (to leave) and that's when Resident #1 lost his/her balance, falling back on the toilet. The toilet was 7 feet 3 inches from the doorway.