Every finding on record at Goldthwaite Health & Rehab Center

Based on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1.The facility failed to dispose of 3 expired cereal containers located on the dry goods storage shelves.2.The facility failed to dispose of 1 expired chocolate topping located in the kitchen's walk-in refrigerator.3.The facility failed to dispose of used cooking oil.4.The facility failed to label and date all food items located in the designated resident refrigerator located in the dining room. 5.The facility failed to ensure dietary staff followed policy and procedure for hand hygiene.6.The facility failed to ensure staff followed policy and procedure for hand hygiene prior to serving food to residents. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 05/12/2026 at 9:03 AM, the following was observed: The facility's kitchen dry goods storage shelving revealed there were 3 sealed plastic cereal containers labeled with date received of 03/05/2026 and shelf life identified as 30 days (04/04/2026). The facility's walk-in refrigerator revealed 1 chocolate topping bottle with an open date of 04/23/2026 and an expiration date of 05/02/2026. Observed used oil in a 20-quart pot dated 05/04/2026. The pot was located beside the stove top. Observation during a walk-thru of the facility's1 dining room on 05/12/2026 at 9:28 a.m., the following was observed:A standalone refrigerator contained 5 food items, each were unlabeled and undated . In an interview on 05/12/2026 at 9:01 AM, with the DS revealed staff had been trained in food safety and prevention of cross contamination. The DS stated it was her responsibility to make sure food storage requirements were met. She stated that the facility guidelines required that food was to be labeled and dated to include the date it was received and the expiration or used by date. She stated that it was her expectation that proper hand sanitation was used by all staff members while they were performing kitchen tasks. She stated that staff were expected to wash hands every time they touch something or start a new task. The DS stated the cereal containers were refilled on 05/06/2026 and that she forgot to label the containers with the correct dates. She stated the chocolate topping bottle was expired and it should have been discarded by the expiration date. The DS stated the oil in the 20-quart pan had been used several times, and it should have been discarded after the first use. The DS stated the nursing staff was responsible for the refrigerator that was in the dining room. She stated the refrigerator in the dining room was to be used for residents' personal food items or food items brought into the facility by family or friends. The DS stated the RD had been working with the facility on kitchen sanitation training. In an interview on 05/12/2026 at 11:05 AM, the DA revealed that handwashing was a requirement for any staff member who worked to prepare or to serve food. The DA stated her job duties included using the dishwasher, stocking food in the refrigerator and on the storage shelves. The DA stated she could not remember when or how she should wash her hands. She stated she had been trained in kitchen sanitation. She said she must use a hair net and that she should not touch anything without washing her hands first. She stated that residents could be susceptible to cross contamination if staff did not use safe sanitation practices. In an interview/observation on 05/12/2026 at 11:11 AM the DC stated she had been trained in hand hygiene and DC stated that residents could get sick if staff do not use proper hand hygiene. Upon observation of the DC during food preparation, it was revealed that she failed to wash her hands between puree preparation tasks. Observed the DC fail to wash her hands prior to beginning puree # 1 (sweet and sour pork). Observed the DC fail to wash her hands prior to beginning puree # 2 (rice). Observed the DC fail to wash her hands prior beginning to puree # 3 (green beans). Observed the DC fail to wash hands upon completion of the purees; she then obtained a milk container from the refrigerator. During an observation 05/13/2026 at 7:13 a.m., observed the DC walk across the kitchen from the food preparation area to the food distribution line. The DC failed to wash hands prior to serving food to plates.During a telephone interview on 05/14/2026 at 1:06 PM, the RD stated that she was a contractor and was not an employee of the facility. She stated she visited the facility once per month and that she had been coming to the facility for over 10 months. The RD said she interviewed residents, and if residents had complaints, if they were newly admitted or readmitted or if there was an unexpected weight loss or gain. She stated she would observe staff in food preparation and on the food line. She said she watched puree, mechanical and regular meal preparation and she observed meal presentation, size and she checked the diet plan being served to each resident. The RD said she believed every staff member should be following protocol regarding hand washing between tasks, and that residents could be at risk for illness if staff did not abide by hand washing policy. She said staff only needed to wear gloves when handling food itself. She stated that staff were supposed to wash their hands between tasks. The RD stated she had a plan for the training of staff regarding handwashing and sanitation, and she expects that she would do the training in her upcoming visit to the facility. In an observation/interview on 05/12/2026 at 11:47 PM, CNA E was observed in the dining room pouring drinks and serving drinks to 9 residents. CNA E failed to use hand sanitation between all 9 drinks being served. CNA E stated she has been trained in hand washing and hand sanitation. She stated her training included the explanation and reason for hand sanitation was to prevent germs from spreading. CNA E stated she had been given a bottle of hand sanitizer but she lent it to another staff member, and she forgot to use hand sanitizer while she was passing drinks and food trays. In an observation/interview on 05/13/2026 at 7:23 PM, the H stated she had been trained on resident rights and hand washing. She stated her role was to provide indirect care for the residents. She stated that her duties included bringing orange juice or water and snacks to the residents. She stated, We are all responsible for sanitation while delivering food. She said, If we don't use hand sanitizer, it could cause cross contamination and cause sickness. The HA was observed using her hands to lift her necklace and putting it to her lips. The HA failed to sanitize her hands before continuing with the duties of serving breakfast trays. Observed the HA deliver food trays on hallway # 3. Observed HA fail to use hand sanitizer prior to delivering meal tray to rooms # 44, # 38, 37 and # 36. The HA could not explain why she was not using hand sanitizer between food service. In an interview on 05/14/2026 at 1:57 PM, the ADM stated that he had been trained in hand sanitation. The ADM stated all staff had been trained in hand sanitation. He stated he believed the nursing staff trained the CNAs on the criteria for hand sanitizing during food service. He said it was his expectations that all the staff who serve food should be using hand sanitizer between meal tray services. He stated if staff failed to follow hands sanitization procedures or food storage and labeling requirements it could cause cross contamination and residents are at risk for food borne illness. Record review of dietary safety training certificates revealed that 5 of 5 staff members had current food safety certifications. The DS's certificate was posted and was current. Review of the most recent training plan records that include Competencies for Food and Nutrition Services Employees revealed the training plan included training on infection control practices and employee hygiene. Review of 5 of 5 staff quizzes confirmed all staff had passing scores. Review of Dietary Services Policy & Procedure Manual 2012.Dry Storage and SuppliesAll facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. Procedures:3. Dry bulk foods ( such as Flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in the food containers or bins. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened.Hand WashingWe will ensure proper hand-washing procedures are utilized. Employees are too frequently perform hand washing as outlined below.Procedures:1 Hand washing occurred in sinks provided for that purpose, sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or about wash basin. 2 The hand-washing technique is as follows:a.Remove rings and watches if they cannot be sanitized during the hand-washing process.b. Competencies For Food And Nutrition Services Employee by (Association of Nutrition & Foodservice ProfessionalsCurriculum:Infection Control Practices/ Employee HygienePractice appropriate hand hygiene during food preparation. to prevent cross contamination.Employs hygienic practices (e.g., not touching hair o face without hand washing) before and during food handling. Property wash hands before serving food to residents after collecting soiled plates and food waste. Demonstrate understanding of infection control precautions per facility's policy/ infection Preventionist. Food Safety RequirementsLabel date and store all food items correctly and in a timely manner.Record review of Hand Hygiene Policy revised 6/2020, revealed, The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure:I.Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. II.Hand hygiene observation may be observed and recorded by the Infection Control Designee monthly and results reported to QA.III.Facility Staff follow the hand hygiene procedure to help prevent the spread of infections to other staff, residents, and visitors. IV.Hand hygiene products and supplies (sinks, soap,. ) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy. V.Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too.A.Wash hands with soap and water:V.After contact with. Environmental surfaces.

Based on observations, interviews, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from Toilet and bathing facilities for 2 (hall 2 and hall 3)of 2 shared resident restrooms reviewed for call lights.1. The facility failed to ensure the hall 2 resident shared restroom call light was accessible from the floor. 2. The facility failed to ensure the hall 3 resident shared restroom call light string was accessible from the shower and was in good repair.These failures could place residents at risk of not being able to call for staff assistance from the floor or shower in the restroom, or in their room, in order to meet their care needs or at risk for injury, pain, hospitalizations.Findings included: In an observation on 05/12/2026 at 11:15 AM of the restroom in hall 2 that was shared amongst residents revealed the call light device to the left of the toilet had no string attached to the metal arm that stuck out approximately half an inch from the wall. In an observation on 05/12/2026 at 12:42 PM of restroom in hall 3 that was shared amongst residents revealed the call light string near the toilet was not reachable from the shower. In an interview on 05/12/2026 at 2:50 PM with RN C, it was revealed that the policy for call lights reflected, residents should be able to reach a call light because they could fall and need assistance. She said that all staff were responsible for making sure the call lights were within reach of each resident. The RN stated she did not know why a call light would not be within reach of a resident. In an additional observation on 05/13/2026 at 10:00 AM of the restroom in hall 2 that was shared amongst residents, revealed the call light device to the left of the toilet still had no string attached to the metal arm that stuck out approximately half an inch from the wall. In an additional observation on 05/14/2026 at 9:21 AM of the restroom in hall 2 that was shared amongst residents, revealed the call light device to the left of the toilet still had no string attached to the metal arm that stuck out approximately an inch from the wall. In an interview on 05/13/2026 at 8:01 AM, LVN D stated she has been trained in resident rights and it was the residents right to get the care they needed while living at this facility. LVN D stated that the facility policy on call lights reflected that call lights were to be within reach of each resident. She stated everyone was responsible for the call light location. She stated that CNAs and nurses each did rounds every 2 hours. She said, Residents are observed at least 1 time per hour. She said she did not know why anyone's call light was not located in a place that they could reach it. She said a resident may not get appropriate care if they can't call for help. In an interview on 05/13/2026 at 12:00 PM, with CNA E, it was revealed that she had been trained on call light placement and call light response times. CNA E stated it was her responsibility to provide direct care for the residents. She stated she worked 6am-6pm and she was responsible for making sure the residents' call lights were within reach of each resident. She stated if she saw a call light on the floor, she was to pick it up and make it accessible for the resident. CNA E said stated she thought a resident could fall or get hurt if they did not have a call light in reach. In an interview on 05/14/2026 9:22 AM with RN A, she stated that approximately 4 residents used hall 2 restroom, and she was aware the call light cord was missing, and the DON had been notified and was getting with the Maintenance Director to replace it. She stated she was not sure when it was removed, or how long the restroom had been without the call light cord but agreed that a resident would not have been able to reach it if they had been on the floor. In an interview on 05/14/2026 at 11:12 AM with the DON, she stated that she had started working on getting the pull cord replaced on 05/14/2026, and she was not sure how long it had been missing for. She stated that when staff noticed it, they should have reported it to maintenance. She stated if the pull string was not there, residents would not be able to reach the light if they were on the floor. In regard to the hall 3 restroom, she stated that they would need to make the string accessible from the shower. In an interview on 05/14/2026 at 1:32 PM with the MTD, he stated he would replace the call light cords in the shared bathrooms when it was reported to him. He stated he was notified on 05/14/2026 that the cord in the hall 2 resident shared bathroom needed replacement. He stated that he checked his maintenance log every morning when he came into work, but some things were verbalized to him, such as the call light cord from earlier in the day. In an interview on 05/14/2026 at 2:00 PM with the ADM, he stated that he was not sure how long the call light cord was missing from the hall 2 resident shared restroom because he hardly ever went in there unless he was helping the MTD with something. He stated that if a resident was on the floor they would not be able to reach the call light switch in that restroom without the pull cord. He stated he would need to look at the hall 3 resident shared restroom to understand the call light identified issue as he could not recall the exact location of the call light. He stated in regard to call lights in resident rooms he stated that call lights were to be within all residents' reach. He stated staff were trained on call light response times and location of call lights when they were in orientation, after that they conducted in-services about the call light buttons often. He stated he felt that the facility could meet the residents' needs. The ADM stated that if a resident were to fall, they needed to be able to reach the call light button to call for help. He said he would expect his staff to follow proper policy and procedure. Review of the facility's maintenance logs dated May 6-14th, 2026 revealed no mention of the hall 2 call light string or the hall 3 bathroom call light cord. Review of the facility's policy titled 'Answering the Call Light' dated September 2022, reflected, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Upon admission and periodically as needed, explain and demonstrate use of the call light to the residents. Ask the resident to return the demonstration.Explain to the residents that a call system is also located in his/ her bathroom.Be sure that the call light is plugged in and is always functioning.5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.6. Report all defective call lights to the nurse supervisor promptly.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for 2 (hall 2 and hall 3) of 2 resident shared restrooms and 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 8 resident rooms reviewed for cleanliness and homelike environments.1.The facility failed to promote a clean, homelike environment in hall 2's resident shared restroom , which had overflowing trash, dirty light switches, and a wet towel in the corner.2.The facility failed to promote a clean, homelike environment in hall 3's resident shared restroom , which had a filthy call light string, corroded caulking and limestone tiles, broken/missing grout in the shower, and the vent fan was covered in dust. 3.The facility failed to have insect screens on the outside of 2 resident room windows observed, and 1 window in hall 3. These failures had the potential to leave residents' feeling like their living space was dirty and hinder the promotion of a homelike environment. Findings included:In an observation on 05/12/2026 at 10:21 AM revealed resident room [ROOM NUMBER]'s window to the outside courtyard was open, and there was air flowing into the room. There was no insect screen on the outside of the window. In an observation on 05/12/2026 at 11:15 AM of the restroom in hall 2 that was shared amongst residents revealed a trashcan overflowing with toilet paper and/or paper towels, onto the floor; urine was still in the toilet bowl; and a wet towel was on the floor near the hand-washing sink. The light switch had an unknown visible brown substance on it.In an observation on 05/12/2026 at 12:42 PM of restroom in hall 3 that was shared amongst residents revealed brown stains on the wall to the left of the toilet; the call light string near the toilet was beige at top and dark brown toward the bottom with obvious signs of wear and filth. Observed damaged and deteriorated grout/caulking at the floor-to-wall transition to the right of the toilet. The seam contained dark discoloration and gaps. In an observation on 05/13/2026 at 9:55 AM of the window in hallway 3 to an outside courtyard revealed the window to have no insect screen affixed to the outside. Resident room [ROOM NUMBER] was able to be observed from this window and also did not have an insect screen affixed to the outside. In an additional observation on 05/14/2026 at 9:21 AM of the restroom in hall 2 that was shared amongst residents revealed the small trashcan was overflowing with toilet paper and/or paper towels onto the floor, and the light switch still had an unknown visible brown substance on it.In an additional observation on 05/14/2026 at 10:15 AM of resident room [ROOM NUMBER] revealed the window to the courtyard was open, letting in air, and no insect screen was affixed to the outside. A lotion bottle was observed holding the window open.In an interview on 05/14/2026 at 10:33 AM with CNA B, she stated that maintenance was responsible for replacing the strings, and the staff could verbally tell maintenance their request. She stated she had not noticed how dirty the hall 3 bathroom floor or call light string was, but that residents did not use that shower as often as they used the hall 1 shower, but the hall 3 shower was still in use.In an interview on 05/14/2026 at 11:12 AM with the DON, she stated that they needed to make the call light string accessible from the shower in the hall 3 restroom. She stated that the grout in the shower would need to be reported to maintenance to see what could be done, and the stains on the wall could be wiped off by anyone, but housekeeping mopped the floors and was responsible for cleaning on a regular basis. She stated she thought there was area of improvement in the bathroom. The DON stated that as far as it not being a homelike environment, that depended on what home was to some people. In an interview on 05/14/2026 at 1:32 PM with the MTD, he stated he would replace the call light cords in the shared bathrooms when it was reported to him. He stated he was notified on 05/14/2026 that the cord in the hall 2 resident shared bathroom needed replacement. He stated that he checked his maintenance log every morning when he came into work. He stated that in the hall 3 restroom they used sandstone, and limestone, and they could corrode if there was a lot of moisture in the air. He stated he was also aware of the residents' rooms needing window screens, for privacy, bug prevention and comfort. In an interview on 05/14/2026 at 2:00 PM with the ADM, he stated that he was not sure how long the call light cord was missing from the hall 2 resident shared restroom because he hardly ever went in there unless he was helping the MTD with something. He stated that if a resident was on the floor they would not be able to reach the call light switch in that restroom without the pull cord. The ADM stated he had not been to the hall 3 restroom lately to see the condition of the corroded floor. He stated that he and the MTD could look at fixing the caulking/grout. He stated that he did not think the restroom conditions had affected any of his residents because no one had complained about it yet, and that the residents were typically very vocal. He stated that they were attempting to obtain more window screens but had not been able to have a company go out to the facility yet.A request for a physical environment/homelike environment policy was made on 05/13/2026 at 12:25 PM, and the a policy on laundry and bedding was provided.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 4 out of 5 residents (Resident #20, Resident #40, Resident #48, Resident #42) reviewed for infection control. MA H failed to disinfect the blood pressure cuff between residents (Resident #20, Resident #40, Resident #48, Resident #42) while performing medication administration. The failure placed residents at risk for cross contamination and the development of infections.Findings include: In observation on 5/12/2026 at 9:03 AM, MA H utilized the blood pressure cuff on Resident #20 and then failed to disinfect the blood pressure cuff prior to use on or in between Resident #40, Resident #48 and Resident #42, In an interview on 5/12/2026 at 10:03 AM with MA H, she stated she was frequently in serviced on infection control. She stated she did not recall if the policy mentioned disinfecting the blood pressure cuff between residents. She did not know of any issues that could occur if the blood pressure cuff was not cleaned. In interview on 5/12/2026 at 3:16 PM with RN C she stated she used to be the infection preventionist. She stated that she was frequently in-serviced on infection control and that it included cleaning the blood pressure cuff between residents. She stated that if reusable medical equipment were not wiped down they could transmit infections from resident to resident. In an interview on 5/14/2026 at 12:03 PM with the DON she stated that it was expected that staff disinfected the blood pressure cuff between residents so as not to spread infections. She stated staff were frequently in-serviced on infection control In an interview on 4/16/2026 at 12:36 PM with the ADM he stated that staff are frequently in-serviced on infection control. When asked if the blood pressure cuff should be cleansed between residents he stated, Well it would be hard to dry since it is fabric. He stated that it could spread infection if it had germs on it. Review of facility policy, Cleaning and Disinfection of environmental surfaces revealed, Environmental surfaces will be cleansed and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration bloodborne pathogens standard.

Based on observations, interviews, and record reviews, the facility failed to provide reasonable accommodations to meet the needs and preferences for 4 residents (Residents # 20, # 24, #28 and # 120) of 14 residents reviewed for accommodations.The facility failed to ensure that Residents # 20, # 24, #28 #47 and #120 had the call light button device in reach. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included:Record review of a face sheet dated 05/13/2026 indicated that Resident #20 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including: Dementia (confusion due to aging with inability to remember), ANXIETY DISORDER, (Characterized by feelings of fear or apprehension about what's to come and persistent and excessive worry) and PARKINSON'S DISEASE, (A movement disorder of the nervous system.). Record review of a Quarterly MDS assessment dated [DATE] for Resident #20 indicated that she had a BIMS score of 03, indicating that she had severe problems with thinking and memory. Resident # 20 was sometimes able to be understood and she sometimes understood others. The MDS indicated she was dependent for all ADLS. Record review of Resident # 20's comprehensive care plan with a revision date 04/07/2026, revealed Resident # 20 requires total assistance to eat and interventions included to encourage the resident to use bell to call for assistance. Record review of a face sheet dated 05/14/2026 indicated that Resident #24 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: CEREBRAL INFARCTION, (is the pathologic process that results in an area of necrotic tissue in the brain), SENILE DEGENERATION OF BRAIN, (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function), VIRAL HEPATITIS ( is an inflammation of the liver that can be caused by viral infections, autoimmune diseases, alcohol, drugs, or toxins.). Record review of a Quarterly MDS assessment dated [DATE] for Resident #24 indicated that his BIMS score was 12, indicating he had moderate problems with thinking and memory. The MDS assessment of Resident # 24's mobility indicated he was dependent; helper does all the effort. Record review of the Care Plan dated 03/16/2026, Revealed Resident #24 has a communication problem r/t Neurological symptom, Stroke. Interventions included, staff are to be sure call light is within reach, respond promptly and encourage the resident to use bell to call for assistance. Record review of Resident #28's face sheet dated 04/23/2026 indicated that Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: INTRACRANIAL INJURY, (Head injuries in adults can range from mild bumps to severe traumatic brain injuries), UNSPECIFIED DEMENTIA (Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives) and ANXIETY DISORDER, (Characterized by feelings of fear or apprehension about what's to come and persistent and excessive worry). Record review of a Quarterly MDS assessment dated [DATE] for Resident #28 indicated a BIMS score of 8 indicating he had moderate cognitive impairment. The assessment of Resident #28's mobility indicated he needed partial / moderate assistance with transfers. Record review of the Care Plan dated 05/12/2026, for Resident #28 indicated the resident's call light was to be within reach and encourage the resident to use it for assistance as needed. Record review of Resident #120 's Face sheet dated 05/13/2026 indicated that Resident #120 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: SENILE DEGENERATION OF BRAIN, (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function) TYPE 2 DIABETES MELLITUS (is a chronic condition characterized by insulin resistance and high blood sugar levels), ANXIETY DISORDER, (Characterized by feelings of fear or apprehension about what's to come and persistent and excessive worry). Record review of a Quarterly MDS assessment dated [DATE] for Resident #120 indicated a BIMS score of 99 indicating she had severe problems with thinking and memory. The assessment of Resident #120's mobility indicated she was dependent and helper does all the effort. The assessment indicated the resident sometimes understood other people and sometimes she could be understood by other people. Record review of the care plan dated 02/26/2026, for Resident # 120 indicated the staff was to be sure the resident's call light is within reach and to encourage the resident to use it for assistance. Resident #120 needs prompt response to all requests for assistance. In an observation on 05/12/2026 at 11:15 AM of the restroom in hall 2 that was shared amongst residents revelae3d the call light device to the left of the toilet had no string attached to the metal arm that stuck out approximately half an inch from the wall. In an observation/interview on 05/12/2026 at 2:05 PM with Resident #20, revealed her call light was observed to be hanging off the right side of the bed, out of Resident #20's reach. Resident #20 shook her head no when asked if she was able to locate the call light button. In an observation/interview on 05/12/2026 2:08 PM., with Resident #24, revealed call light was located in his room, on the bedside table and resident was not able to reach it. Resident #24 responded that he did not know where his call light was located, and he did not know how he would contact staff if he required help. In an observation/interview on 05/12/2026 at 3:52 PM, with Resident #28's, revealed call light button was observed in his room and to be hanging off the right side of the bed, out of the resident's reach. Resident #28 stated that he was not aware of the call light location. In an observation/interview on 05/12/2026 at 2:07 PM of Resident #120, revealed she was lying , in her bed on her right side facing the wall. Her call light was located between the mattress and bedframe. Resident #120 did not have access to a call light button. Resident #120 responded to questions regarding the call light by shaking her head no. Resident #120 indicated she did not know where the call light was and she could not use it to get in touch with the staff. In an interview on 05/13/2026 at 8:01 AM, LVN D stated she has been trained in resident rights and it was the residents right to get the care they needed while living at this facility. LVN D stated that the facility policy on call lights reflected that call lights were to be within reach of each resident. She stated everyone was responsible for the call light location. She stated that CNAs and nurses each did rounds every 2 hours. She said, Residents are observed at least 1 time per hour. She said she did not know why anyone's call light was not located in a place that they could reach it. She said a resident may not get appropriate care if they can't call for help. In an interview on 05/13/2026 at 12:00 PM, with CNA E, it was revealed that she had been trained on call light placement and call light response times. CNA E stated it was her responsibility to provide direct care for the residents. She stated she worked 6am-6pm and she was responsible for making sure the residents' call lights were within reach of each resident. She stated if she saw a call light on the floor, she was to pick it up and make it accessible for the resident. CNA E said stated she thought a resident could fall or get hurt if they did not have a call light in reach. In an Interview on 05/14/2026 at 1:57 PM , with ADM, it was revealed that he stated staff are trained on call light location and response times when staff are in orientation. He said after orientation, staff are in-serviced about call light placement location. Review of the facility's policy titled 'Answering the Call Light' dated September 2022, reflected, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.1.Upon admission and periodically as needed, explain and demonstrate use of the call light to the residents.2. Ask the resident to return the demonstration.3.Explain to the residents that a call system is also located in his/ her bathroom.4.Be sure that the call light is plugged in and is always functioning.5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.6. Report all defective call lights to the nurse supervisor promptly.

Based on observations, interviews and record review the facility failed to establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 residents reviewed for pharmacy services. (Resident #44)The facility failed to account for controlled substances for Resident #44.This failure could put residents at risk for not having medications administered as ordered by physician.Findings included:Record review of Resident #44's face sheet reflected a [AGE] year-old female admitted [DATE] with diagnosis of Cerebral Infarction (stroke) due to occlusion of small artery, Type II Diabetes Mellitus, Hypercalcemia (high blood calcium), Osteoarthritis of the left knee, history of Transient Ischemic attach (mini-Stroke) without residual effects, Epilepsy (seizures).Review of resident #44's MDS dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment.Review of Resident #44's current physician's orders reflected an or for Acetaminophen-Codeine Tablet 300-30 MG (Tylenol #3) Give 1 tablet by mouth two times a day for pain.Review of Resident #44's MAR reflected that she had not missed a dose of the prescribed narcotic. In an interview on 05/12/2026 at 2:21 PM with Resident #44, she stated that she got her pain medication as scheduled two times a day. She stated that the medication was effective and she had not missed any doses due to facility being without her Tylenol #3 for a few days. Review of the receipt received from the pharmacy, utilized by the facility, on 05/14/2026 at 8:45 AM. revealed that Tylenol #3 was received on 05/02/2026 and was signed by MA GIn a telephone interview on 5/14/2026 at 11:38 AM with MA G, she stated that she did recall receiving a card of Tylenol #3 on 05/02/2026 and she stated she placed it in the cart containing medications for hall #1. She stated that she ensured there was a controlled medication count sheet placed in the book and the medication card was in the lock box of the cart. She stated she recalled the card being accounted for when she worked on 05/06/2026 and 05/07/2026.In an observation on 5/14/2026 at 11:40 AM revealed all controlled medication was accounted for and medication control count logs were signed ongoing and off going shifts. In an interview on 5/14/2026 at 11:45AM with MA H, she stated that she was working on 5/8/2026 when it was noticed that Resident #44 was out of Tylenol #3. She stated that later on she remembered seeing the card and the narcotic sheet that morning but not for the evening. She stated that the charge nurse and the DON would also have access to the cart at times if needing to give a PRN medication. She stated that they mostly counted narcotics when handing over cart keys for breaks but always when handing over for another shift. She stated that at evening medication pass she noticed there was not Tylenol #3 for Resident #44 and utilized the emergency kit following instructions from the DON and ADM. She stated at the time they thought maybe the pharmacy was low on doses and only provided a portion. She stated she was suspended until drug testing could be completed and her results were negative and she was able to return to work. She stated that following the incident they were in-serviced on abuse/neglect/misappropriation of property and narcotic counts with the new log sheet for counting the total items and the controlled medication sheets so they could ensure nothing went missing.In an interview on 5/14/2026 at 11:59AM with RN A, she stated that there were two sets of keys to each medication cart and that the DON had the spare and the medication aide typically had the other set but if they went on break the charge nurse would cover and hold the keys. She stated that they performed controlled medication counts when handing over the keys to the cart. She stated that she was called 5/8/2026 and asked to come in for a drug test and told she was suspended until the results came in. She stated she did not recall giving any controlled medication on 5/8/2026 or using the control box on the cart. She stated she did not give the medications that often so she did not recall what controlled medications were in the cart when counting controlled medications. She stated when she came back with the ok of the ADM she was in-serviced on abuse/neglect/misappropriation of property and narcotic counts with the new log sheet for counting the total items and the controlled medication sheets so they matched.In interview on 5/14/2026 at 12:03 PM with the DON, she stated that while she had access to the medication carts she did not utilize them on 5/8/2026. She stated that they should be counting when handing off cart keys. She stated there were two sets of keys for the 2 medication carts and one set was kept by her for emergencies. She stated that when it was reported on 05/08/2026 that Resident #44 was out of her Tylenol #3 they thought it was either delayed from the pharmacy or they had only given them a partial order as they sometimes did when they did not have enough for a full order on hand. She stated that on Monday 05/11/2026 they followed up with the pharmacy and were told they should have almost a full card, and she found a receipt for delivery and informed the ADM and they immediately checked to ensure all other controls were accounted for and that it did not get misplaced. She stated since she had access she and all others who had access were drug tested and suspended until the results came in. She stated that they had not been able to determine what happened to the card. She stated following the incident all staff were in-serviced on abuse/neglect/misappropriation of property and those that ad access were in-serviced on narcotic count and the new sheet they developed on counting controlled medication count sheets and controlled medication bottles, syringes and cards. In an interview on 5/14/2026 at 12:36PM with the ADM, he stated that on Friday 05/08/2026 late evening the resident was noted to be out of Tylenol #3. He stated there was no control sheet to trigger that a card was missing. He stated they suspected at the time that the pharmacy had not delivered it or the pharmacy owed doses which had happened on occasion. He stated the resident did not miss any doses of her prescribed medication as they utilized the facility's emergency kit. He stated that they attempted to follow up on a reorder on Monday, 05/11/2026 and learned the facility had received a card of Tylenol #3 with a quantity of 60 tablets on 05/02/2026. He stated they estimated that if they had used the card starting that day it would have between 47 and 60 tablets remaining. He stated he watched camera footage and could not see that anyone had removed the medication from the cart. He stated that the employees who had access to the medication cart on the previous shift were all suspended until drug testing was completed. He stated he did not know who signed for the medication when it arrived and was attempting to obtain a copy of the signed receipt from the pharmacy. He stated he and the DON recounted all controlled medications and there were no other discrepancies. He stated they created an additional count sheet that would now include how many controlled items (blister packs, bottles, etc.) and how many controlled medications count sheets there should be. Review of facility policy-controlled substances revised November 2022 it revealed, the facility complies with all laws and regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Prevention and Control Act of 1976). The policy states that, the charge nurse on duty maintains the keys to the controlled substance containers. The DON maintains a set of backup keys for all medication storage area including keys to controlled substance containers., Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.

Based on interview and record review, the facility failed to ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. (i)Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii)The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section for 1 of 5 residents (Resident #1) reviewed for inappropriate discharge. The facility failed to include the basis for the transfer made by a physician in Resident #1's medical record. This failure placed residents at risk of unmet medical needs and rehospitalization.Findings included: Review of the hospital referral document for Resident #1 dated 12/04/2026 reflected he was struck in the head by a train guardrail on 11/03/2026 and was recovering from a severe traumatic brain injury It reflected agitation and restlessness but no aggression, verbal or physical. Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included traumatic brain injury, schizophrenia, and history of methamphetamine use. Review of the admission MDS for Resident #1 dated 12/08/2026 reflected he could not participate in a BIMS assessment. The staff assessment for mental status reflected he demonstrated inattention and disorganized thinking. The MDS reflected he exhibited the behavior of verbal aggression and other behavior symptoms (e.g. Physical symptoms, such as hitting or scratching self, pacing, rummaging, public, sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds). It also reflected Resident #1's behavior significantly intruded on privacy activity of others and significantly disrupted care or living environment. Review of the care plan for Resident #1 dated 12/08/2025 reflected the following:Focus area: (Resident #1) exhibits potential to exhibit behavioral symptoms: may refuse medications, may become agitated/angry easily, may exhibit acting out/outbursts, yelling, and can become confrontational, both physical, and verbal against other Residents/Staff. He may exhibit cursing, and verbal/physical aggression towards Staff & Residents, he may exhibit restlessness, & Psychosis, etc.Goals: (Resident #1) will not exhibit behavioral symptoms through the review date. (Resident #1) will verbalize in an appropriate manner his feelings, thoughts, needs, problems, concerns, etc., through the review date.Interventions: (Resident #1) will receive linkage to Resources/Referral Agencies as needed through the review date. LBSW will provide support to Resident, (Resident #1), re: health condition, physical, and mental limitations, problems, concerns, etc. LBSW will encourage (Resident #1) to exhibit appropriate behaviors within the Nursing Home. LBSW will encourage (Resident #1) to exhibit appropriate behaviors towards Staff and other Residents. LBSW will encourage (Resident #1) to verbalize in a calm, and appropriate manner his feelings, thoughts, needs, problems, concerns, etc., within the Nursing Home. LBSW will provide linkage to Resources/Referral Agencies as needed within the Nursing Home. Review of the progress notes for Resident #1 from 12/05/2025 to 12/08/2025 reflected the following:*12/06/2025 at (12:16 AM) written by LVN F Pt became extremely agitated and attempted to go out for a cigarette at 00:16. SN attempted to redirect pt. with little success. Offered snacks and diversion to behavior. Raised voice pushed W/C into wall. Pt settled and was assisted with snacks and drinks back to his room. He believes he can go out at all hours of the NOC. Re-educated about appropriate schedule smoke break times. (FM) suppose to visit on Sat.12/6/2025 to bring belongings and cigarettes for this resident. *12/06/2025 at (12:21 PM) written by LVN B This nurse discussed resident's recent behaviors/outbursts with FM and family. Resident's (FM) stated, anytime he is acting out just call me and he will settle down. (FM) stated that resident eats a lot and needs larger portions. (FM) gave permission to d/c order for nicotine patch due to resident unable to smoke when he was in the hospital. Family provided nursing staff with more cigarettes for resident. (FM) also requested that resident have lab work done (CBC (type of blood test measuring the number of certain blood cell types)), CMP (type of blood test measuring metabolic function), HGBAIC (blood test that measures the level of sugar in your blood over the previous three months), VALPROIC ACID (sedative medication used for seizures and agitation)) to check levels. (FM) explained that resident responds better to being called, (Resident #1 nickname). *12/08/2025 at (02:05 PM) written by LBSW On this date, Administrator, reported for LBSW to see if we can get Resident, (Resident #1) accepted into (Behavioral Hospital) in (city, state), for he has been having behaviors within the Nursing Home. Administrator, reported he will call his (FM) to let her know that Resident, (Resident #1) is in need of going to (Behavioral Hospital) in (city, state) due to his behaviors. Therefore, LBSW contacted (Behavioral Hospital) in (city, state) and talked to Admissions and she suggested to have the required paperwork sent to their email address: Therefore, Resident, (Resident #1) paperwork was sent to their email address for (Behavioral Hospital) in (city, state) to see if they will accept Resident, (Resident #1) admission. Later, LBSW received a call from Admissions (staff) at (Behavioral Hospital) in (city, state) Admissions asked if Resident, (Resident #1) is ambulatory, and can he do his own ADLs, and LBSW informed her that Resident, (Resident #1) walks and he does his own ADL's. Therefore, Admissions (staff) reported that they have accepted Resident, (Resident #1) into (Behavioral Hospital) in (city, state). Therefore, LBSW traveled to County Courthouse and visited with Judge and he signed the Emergency Detention forms as required, at this time. Therefore, ([NAME] agent) transported Resident, (Resident #1) to (Behavioral Hospital) in (city, state). LBSW called (Behavioral Hospital) in (city, state) and informed Admissions (Staff) that County Officer, ([NAME] agent) is transporting Resident, (Resident #1) and enroute to (Behavioral Hospital) at this time. Also, informed Admissions (staff) that ([NAME] agent) has the required Emergency Detention Paperwork, and all other paperwork as needed. LBSW offered support and offered any assistance needed. Review of the behavioral health hospital records for Resident #1 dated 12/23/2025 reflected he was continuing with angry behavior and had to be monitored for aggression but was ready for discharge. Review of physician orders for Resident #1 with a date range of 12/05/2025 to 12/31/2025 reviewed on 01/08/2026 reflected no order related to Resident #1's discharge. Review of assessments for Resident #1 from 12/05/2025 to 12/31/2025 reflected no discharge assessment or summary signed by a physician. Review of miscellaneous documents for Resident #1 from 12/05/2025 to 12/31/2025 reflected no discharge summary or discharge order signed by a physician. During an interview on 01/08/2026 at 09:30 AM, the ADM stated Resident #1 arrived on a Friday (12/05/2025), and they had a horrible weekend with his behaviors. The ADM stated he was getting calls from residents and their families that they would have to leave the facility if the behavior continued. He stated Resident #1 was refusing his medications and would not calm down. He stated the behavior was going on all hours of the night and day. He stated they finally sought a Peace Officer Emergency Detention from law enforcement and Resident #1 was taken to the behavioral health hospital. The ADM stated they were planning to admit him back once his medications were sorted out, but the behavioral health hospital reached out to them stating he was ready for discharge from their facility on 12/22/2025, and the clinical paperwork received from the behavioral health hospital still included similar behaviors occurring on 12/23/2025, so they did not feel it was safe to accept him back. The ADM stated they had a very quiet, older population, and Resident #1 should have gone to a facility with younger residents, more liberal smoking rules, and more residents with psychiatric issues. The ADM stated the referring hospital did not tell them the whole story, so they did not know they were admitting someone with the types of anger issues Resident #1 had. The ADM stated he spoke with the ombudsman about the situation, and she had told him she understood. He stated she provided him with a list of facilities that might accept Resident #1 and be a more suitable fit for him. He stated he had spoken to a couple of facilities after he had determined they could not readmit Resident #1 to help the behavioral health hospital find a suitable placement for him, and he had selected one alternate facility that was ready to accept Resident #1 once the ADM sent over his referral paperwork. The ADM stated he called Resident #1's FM to get her permission to send the paperwork, but she never returned his call. He stated he called her at least twice and did not have an email address for her. He stated after that, he had learned from the behavioral health hospital that the family decided to care for Resident #1 in the community/at home, so he stopped working on it. He stated this investigation was the first he had heard about it in two weeks. During an interview on 01/08/2026 at 12:31 PM, the MD stated she had not seen Resident #1 in person, because he was only at the facility over one weekend before being sent out. She stated he was sent to the behavioral health hospital. She stated that she had reviewed the notes and the behavioral health hospital notes and did believe that Resident #1 was a danger to other residents in the facility. She stated there was a danger of psychosocial harm from his verbal aggression and behaviors of slamming things down, pushing things off surfaces, and other types of physical aggression. She stated he could also escalate to physical aggression since he already demonstrated these other forms of aggression. She stated she regularly signed discharge summaries and was not sure why she was not asked to sign a discharge summary for Resident #1, but if she had received the paperwork, she would have signed it. She stated this was the first situation they had experienced at the facility like this, and it was because the referring hospital was not honest on his referral paperwork. She stated the facility would not have admitted him if the hospital had charted his behaviors honestly. During an interview on 01/08/2026 at 02:55 PM, LVN A stated many of the other residents were nervous around Resident #1 and did not feel comfortable with him due to his outbursts. She stated he himself voiced the facility was not a good place for him, because it had an older population and a quiet, peaceful environment. He would threaten to beat people up if he did not get to smoke whenever he wanted to. She stated he became physical with items on the halls and was throwing items down and slamming his hand on things. During an interview on 01/08/2026 at 03:09 PM, LVN B stated Resident #1 got ugly with the med aide on 12/07/2025 and he threatened to throw everything and was up and down the hallway yelling he was going to beat somebody's effing ass. She stated the residents were calling their RPs and telling them they were scared. She stated they had admitted a new resident the day this was going on, and it was scary for the new resident for that to be the first thing they saw. She stated they had to corral all the residents to stay in their rooms while he was doing this, because they did not know what he could do if any residents got in his way. A telephone interview with the LBSW was attempted on 01/08/2026 at 03:15 PM. A voicemail was left with no reply as of 01/16/2026. During an interview on 01/09/2026 at 08:18 AM, CNA E stated she monitored Resident #1 during smoke breaks for the weekend he was in the facility. She stated he frequently got irritated, yelled, and cussed. She stated some of the residents were intimidated by him and did not go out to smoke while he was out there. She stated they generally had a very peaceful environment at the facility, and Resident #1's behaviors stood out. She stated they received lots of training on managing aggressive behavior, but none of the methods worked with Resident #1. During an interview on 01/09/2026 at 08:24 AM, MA C stated she worked the weekend Resident #1 was in the facility. She stated he was very demanding and if he was not given what he wanted, he would go into a cussing fit and slam his hand down on the medication cart or something else. MA C stated the charge nurse over the weekend was worried about her safety and after he was going to hit MA C. MA C stated she was not as afraid, but she did move into the nurse's station when the charge nurse (LVN B) asked her to instead of remaining by the medication cart. During an interview on 01/09/2026 at 10:33 AM, MA D stated she worked as the medication aide on 12/08/2025 when Resident #1 was sent to the behavioral health hospital. She stated all the residents were very upset that day, as he was loud, obnoxious, and aggressive. During an interview on 01/09/2026 at 10:52 AM, the ADM stated he did not know they had to get a signature from the physician on the documentation that explained the basis for the emergency discharge. He stated he felt confident that Resident #1 was not safe to be in the facility, but he was not aware of all the documentation requirements. He stated he had been the DON at the facility for ten years and had just started as the administrator a few months prior and was still learning. He stated the DON was the person responsible for ensuring all the aspects of the discharge process were compliant. He stated he monitored for compliance by reviewing every resident who went to the hospital, discharged home, expired, or transferred. He stated he did not think the failure to obtain a physician signature on the documentation for the emergency discharge would affect a resident, but it did make an incomplete medical record. During an interview on 01/09/2026 at 10:59 AM, the DON stated she had started in her position on 11/10/2025 and was still learning. She stated the person responsible for making sure the discharge process was compliant was her and the ADM as a backup. She stated she ensured compliance by making sure everything in the chart was reviewed and sent to interested parties as needed. She stated she could not think of the potential negative outcome of not having a physician signature on the documentation for emergency discharge, but it put them out of compliance. During an email interview on 01/09/2026 at 11:10 AM, Resident #1's FM stated she would not want Resident #1 to return to the facility. During a telephone interview on 01/09/2026 at 12:00 PM, Resident #1 stated he did not want to return to the facility and did not belong there. He stated he was doing well in a rental near his family, and they checked on him. He stated he was able to take care of his own ADLs and his family made sure he took his medications. He stated he was safe and comfortable where he was. Review of In-services from October 2025 through January 2026 reflected the following: Handling aggressive behavior 10/06/2025, 10/11/2025, and 10/28/2025. Review of facility policy dated October 2022 and titled Transfer or Discharge, Facility-Initiated reflected the following: Policy StatementOnce admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers, and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.Policy Interpretation and Implementation 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless:c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;Notice of Transfer or Discharge (Emergent or Therapeutic Leave)3. Under the following circumstances, the notice is given as soon as it is practical, but before the transfer or discharge: A. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;Notice of Discharge after TransferIf discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the residence status at the time the residence seeks returned to the facility not at the time the resident was transferred to acute care.Documentation of Facility-Initiated Transfer or Discharge1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record:a. The basis for the transfer or discharge;3. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the residence clinical record by a physician:A. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for one of one kitchen reviewed for food storage and sanitation, in that: 1. The facility failed to ensure food in the walk-in refrigerator freezer were labeled and dated. 2. The facility failed to ensure food on the shelf was covered, labeled, and dated. These failures could place residents at risk of foodborne illness. Findings included: Observation of the Kitchen on [DATE] at 08:45 AM during initial tour of kitchen, the walk-in refrigerator had a box of yogurt with an expiration date of [DATE]. Observation of the Kitchen on [DATE] at 9:10 AM while conducting the initial tour of the kitchen, a shelf with apples and bananas revealed brown bananas, an open and expired pack of tortillas dated [DATE]; a pack of strawberry gelatin in a zip lock bag that was dated [DATE]; and a pack of either lemon gelatin or cake mix in an undated open bag. Interview with the DM on [DATE] at 09:50 AM, she stated if residents were served expired food, they could get sick. The DM stated that it was her responsibility for daily to check for expired foods. DM stated she was implementing a new policy of labeling opened food items with a printed label that indicates date item is opened, expired, and a use by date. The DM stated her kitchen staff were trained on checking for expired food and labeling/dating opened food items. Interview with the DA on [DATE] at 11:28 AM, she stated if residents were served expired food, they can get sick. The DA stated they were to check for expired food daily. The DA stated she has been trained on checking for expired food and labeling/dated opened food items. The DA stated per her training, she learned to label open food in a sealed container with the date, a use by date, her initials, and the expiration date. The DA stated that they were also not to use expired food. Interview with the [NAME] on [DATE] at 11:32 AM, she stated residents could get food poisoning or sick if they received food that was expired. The [NAME] stated she checks food daily as she works. The [NAME] stated she has been trained on checking for expired food and labeling/dated opened food items. The [NAME] stated per her training, they were not to use expired food. When she opens food, it needs to be labeled with the date opened, use by date and expiration date. Observation of the refrigerator on [DATE] at 9:44 AM, refrigerated items that have been opened were labeled with a printed label indicating open date, use by date, and expiration date. Opened sliced cheese was wrapped in plastic wrap and labeled by handwritten open date [DATE] but it was missing the use by date. Interview with the DON at [DATE] at 2:15 PM he stated he stated if a resident received expired food, the potential harm was they can become sick. The DON stated it was the dietary manager responsibility to make sure expired food was discarded. The DON stated residents receiving expired food does not meet his expectation. Interview with the ADM at [DATE] at 2:25 PM he stated if a resident had received expired food, the potential harm was they can become sick. The ADM stated it was the dietary manager's responsibility to make sure expired food was discarded. The ADM stated residents receiving expired food does not meet his expectation. Review on [DATE] at 10:15 AM revealed Policy entitled Dietary Services Policy and Procedures Manual including Food Safety and Storage Refrigerators, revealed The facility will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in the compliance with all State, Federal, and local laws, and regulations. Food shall be managed in a safe manner. Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. Food must be covered when stored, with a date label identifying what is in the container.

Based on interview, and record review the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #43) of six residents reviewed for PASRR evaluation and screening. The facility failed to refer Resident # 43 to the appropriate state designated MH/ID authority for evaluation. Resident #43 was diagnosed with a mental illness prior to admission. This failure could place residents at risk of risk of not being assessed by the local MH/ID authority and not receiving mental health services to address and prevent decline. Findings included: Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024 reflected diagnoses were, Schizoaffective Disorder, Bipolar Type (a mental health condition of both schizophrenia and bipolar disorder, that caused manic episodes, increased energy and feelings of sadness and hopelessness), Anxiety Disorder (extreme fear or worry), Metabolic Encephalopathy (a change in how your brain works due to an underlying condition), Depression (mood disorder that causes persistent feeling of sadness and loss of interest) and Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful or terrifying event). Resident #43's care plan did not address his schizoaffective disorder and PTSD. Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Section A1500 Pre-Admission Screening and Resident Review (PASRR). The question Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? was coded as zero which indicated a response of no to the question. Review of Resident #43's PLI dated 10/04/2025, completed by an acute care hospital reflected a diagnosis of altered mental status and Section C - PASRR Screening C0100.Mental Illness is checked No and C0200. Intellectual Disability is checked No. Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was receiving psych services two times per month. During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building after an outside smoke break. The resident was walking down the hallway with his head down. Resident #43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said his intention was not to offend the surveyor. During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated prior to admission they reviewed the PL1 to determine if the resident had a MH/ID diagnosis. She said if the resident had a negative PL1 and had a MH/ID diagnosis they should have submitted a PLI. She said, I feel like we meet the needs of the residents. The resident would not get the proper care if appropriate psych services were not provided. Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a PLII, and the facility provided psych services via a contracted provider. During an interview on 3/19/2025 at 2:15 PM, the DON stated the facility reviewed previous health records and the ADM has gone to meet the resident to determine if the resident was a good fit for the facility. He stated the MDS nurse was responsible to complete and submit the PASRR evaluation. He said if a resident's PL1 screening was negative, the facility provided in-house psychiatric services via a contracted provider. Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a PLII, and the facility provided psych services via a contracted provider. He said the [NAME] from hospitals were most often negative and inaccurate. He said they met the needs of Resident #43 and placed the resident on psych services. During an interview on 3/19/2025 at 2:25 PM, the ADM stated the MDS nurse was responsible to complete and submit the PASRR evaluation. He also said they provide psychiatric services through a contracted provider. The facility's PASRR policy was requested on 3/192025 at 2:30 PM, and the facility did not have a related policy. Review of the facility's policy Admission Criteria revised March 2019 reflected the following: 9. 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. a. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified. 10. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital. 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital; and c. the attending physician has certified (prior to admission) that the individual will need less than 30 days of care at the facility.

Based on observation, interviews and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for one (Resident #43) of six residents reviewed for quality of care. The facility failed to ensure Resident #43's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024, reflected diagnoses were Schizoaffective Disorder, Bipolar Type (a mental health condition that affects how people think/behave and causes manic episodes, increased energy and feelings of sadness and hopelessness), Anxiety Disorder (extreme fear or worry), Metabolic Encephalopathy (a change in how the brain works due to an underlying condition), Depression (mood disorder that causes persistent feeling of sadness and loss of interest) and Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful or terrifying event). No goals and interventions were documented to address and/or mitigate the triggers for Resident #43's documented PTSD diagnosis. Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Section D - Mood, reflected Resident #43 rarely felt isolated from others. Section E - Behaviors, reflected Resident #43 had no hallucinations or delusions. Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was receiving psych services two times per month. During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building after an outside smoke break. The resident was walking down the hallway with his head down. Resident #43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said his intention was not to offend the surveyor. During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated she and the DON were responsible to complete care plans for residents. She said the nursing staff who cared for a resident diagnosed with PTSD would have been aware if a resident needed a different type of care and staff reported no issues. She stated she was unaware Resident #43's triggers were not care planned. During an interview on 3/19/2025 at 2:15 PM, the DON stated he completed the initial comprehensive care plans and the MDS Nurse completed the care plan updates. He said residents who had a PTSD diagnosis were offered psych services through a contracted provider and they had made concessions for residents who needed more 1:1 care. He said a resident's triggers would have been identified through staff interactions and then reported to him. He said, We have a few PTSD residents and have not had any specific interventions for those residents. Additionally, he stated Resident #43 did not have behaviors related to PTSD and that it should have been care planned. He said they met the needs of Resident #43 and placed the resident on psych services. During an interview on 3/19/2025 at 2:25 PM, the ADM stated residents with a PTSD diagnosis were offered psych services. When asked how the facility identified triggers for residents with a PTSD diagnosis, he stated they have gone through trauma training. He said the DON was responsible to ensure care plans were updated with goals and interventions. When he was asked to identify negative outcomes for residents who did not receive the appropriate services, he said it was speculation and he could not answer that question. Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised in March 2022 reflected the following: Policy Statement - A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a) Includes measurable objectives and timeframes; b) Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including: (2) any specialized services to be provided as a result of PASRR recommendations; and c) Includes the resident's stated goals upon admission and desired outcomes; d) Builds on the resident's strength; and e) Reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a) Provided by qualified persons; b) Culturally competent; and c) Trauma-informed 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 5 of 9 residents (Residents #1, #2, #3, #4, and #5) reviewed for abuse. 1. The facility failed to prevent COTA D from sexually abusing Resident #1 when COTA D had intercourse with the resident in the resident's room after the resident was on the therapist's caseload. 2. The facility failed to protect Resident #2 when COTA D removed the resident's pants for therapy treatment. 3. The facility failed to prevent COTA D from touching Resident #4 and Resident #5's buttocks while rubbing their back during their therapy session. 4. The facility failed to prevent COTA D from touching Resident #3's buttock and genitalia while rubbing her back during her therapy session. An Immediate Jeopardy (IJ) was identified on 5/23/2024. The IJ template was provided to the facility on [DATE] at 4:43 p.m. While the IJ was removed on 5/25/2024, the facility remained out of compliance at a scope of pattern, with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of sexual abuse from facility staff. Findings include: 1. Record review of Resident #1's face sheet, dated 5/24/2024, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and had diagnoses that included hypertensive heart disease with heart failure (heart problems caused by long-term heart pressure), morbid obesity due to excessive calories (weight that is 80 to 100 pounds above their ideal body weight), body mass index (a ratio of your weight to your height) of 70 or greater, type 2 diabetes mellitus (when the pancreas does not make insulin), sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (frequent feelings of fear and worry that is intense and excessive). Record review of Resident #1's care plan, initiated 11/22/2021, reflected the resident had a potential to exhibit withdrawal from activities and socialization due to health condition, physical, and mental limitations, problems, concerns, etc. The care plan interventions included the Social Worker providing support and verbalization of feelings, thoughts, needs, problems, and concerns. Record review of Resident #1's annual MDS assessment, dated 12/22/2023 reflected a BIMS score was 15, which indicated the resident was cognitively intact. Resident #1 had no mood or behavioral concerns and used a walker and wheelchair for ambulation. Record review of Resident #1's May 2024 Consolidated Physician Orders reflected an order, with a start date of 10/12/2023, that the resident had Occupational Therapy 4 times a week for 30 days. Record review of the Facility Incident Report, dated 2/29/2024, reflected Resident #1 reported to the facility during the months of September and October 2023, COTA D had gaslight me and groomed me for a relationship and she realized he had been taking advantage of her. The report reflected COTA D had intercourse with Resident #1 in the resident's room. Record review of the Police Report Case Identification Number 24-00293, dated 2/29/2024, reflected the police were informed by the facility of COTA D's inappropriate sexual behavior with residents. Record review of COTA D's personnel file revealed the COTA was hired on 5/22/2024, suspended on 2/21/2024, and his employment was terminated on 2/28/2024. The personnel file revealed COTA D was given a verbal warning on 10/12/2024 regarding following professional boundaries because of a rumor that he and Resident #1 were planning to move in together after the resident was discharged . On 1/8/2024 COTA D was given a written warning because he was not following the residents plan of care, Medicare guidelines for documentation and he was working overtime without approval. A disciplinary action form initiated 2/27/2024 and signed on 2/28/2024 revealed COTA D was terminated due to inappropriate relations and unprofessional conduct with facility a facility resident and former resident. During an interview on 5/22/2024 at 10:27 a.m. with the PNP she stated the SW referred Resident #1 when information came out about the resident's intimate relationship with COTA D. The PNP stated the resident was vulnerable when COTA D began taking interest in the resident. The PNP reported as their relationship progressed, COTA D told Resident #1 he could provide her a stable relationship and a home for them to live together. The PNP stated Resident #1 expressed increased depression, so she increased the resident's antidepressant dosage. The PNP stated Resident #1 scored high on her anxiety assessment, but the resident was already on an anti-anxiety medication, and the resident did not appear anxious during their meeting. The PNP reported she could not say for sure if the incident made the resident mentally upset, and because the resident was already depressed before the incident, the PNP stated it was difficult to gauge what emotional impact the incident had on the resident. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1 she stated she began receiving occupational therapy with COTA D and continued having a relationship until her surgery in November 2023. Resident #1 stated the COTA started grooming me from the beginning, telling the resident she was a beautiful woman and how great she would look when she lost weight (Resident #1 was scheduled for Lap band surgery in November 2023). Resident #1 reported when she first began working with COTA D, she was engaged to another male living in the community and the COTA was aware of their relationship. Resident #1 stated when she began having problems with her relationship with her fiancee, she would confide in COTA D, and he was supportive. Resident #1 stated she was in a vulnerable state when their romantic relationship began in September 2023. She reported COTA D was her Knight in Shining [NAME], telling her he bought a house for them to move in together and he would paint pictures of a fabulous life and how he would take care of me. Resident #1 reported at that time the COTA was taking her out to eat in the evenings at a restaurant nearby and he would take her to lunch to meet her family, who were visiting from out of town. Resident #1 stated at first COTA D did not stay when he took her to see her family, but a short time later he began joining them for lunch. Resident #1 also reported it was in September 2023 that they had intercourse in the resident's room. Resident #1 reported it was late in the evening, and COTA D checked that all the department heads left for the day. Resident #1 reported they only had intercourse one time. Resident #1 stated in November 2023, their relationship ended, however, the COTA would still kiss her and rubbed her buttocks during her cryotherapy (or cold therapy, where low temperatures are used as part of the therapy treatment to relieve muscle pain or swelling after surgery). Resident #1 reported she found out later that COTA D told her fiancee he never had any intention of the resident moving in with him, and he only said this to motivate her in therapy. The resident reported staff would see them together, but COTA D never did anything inappropriate in front of them. Resident #1 reported the Administrator had asked her in September 2023 if she and the COTA had a serious relationship and she told the Administrator they were just friends. She also reported the Administrator asked her again about a relationship between her and COTA D in November, and she told him no. The resident reported by that time it was over and she was telling the truth. Resident #1 stated only one resident asked her if she was having a relationship with COTA D. Resident #1 reported COTA D was still calling her after he no longer worked for the facility, and she told him to stop calling her and he blocked his phone number on her cell phone. During an interview on 5/22/2024 at 1:56 p.m. with CNA B, she stated she saw COTA D take Resident #1 to the nearby restaurant and the COTA stated they were going out to eat with her family and it was part of her therapy. The CNA stated she never saw COTA D take any other resident outside of the facility. CNA B stated she thought it was odd the COTA was taking the resident out to eat but she never told anyone. CNA B could not provide a reason why she did not tell anyone. During an observation and interview on 5/22/2024 at 2:55 p.m. with HA C she stated after the first State Surveyor went to the facility to investigate the incident, the CNA the resident was not herself and appeared more depressed now that she began telling others about her past relationship with COTA D. During a telephone interview on 5/24/2024 at 3:00 p.m. with Resident #1's FEC she reported she first met COTA D in September 2023 at the facility. The FEC stated the COTA was cordial but felt conversations with the COTA were forced conversations. Resident #1's FEC stated when they ate with Resident #1 and COTA D, the COTA stated he was looking for wife-material, referring to the resident. The FEC stated at the time Resident #1 had another boyfriend who lived in the community but stated COTA D promised to move her in with him in his new home. The FEC stated they had lunch with the COTA at least 4 times. The FEC stated she recalled another incident when she saw COTA D working with another resident, the COTA helped the resident up from the chair holding her buttock instead of under the resident's arms. Resident #1's FEC stated she could not recall when this occurred, and she did not know who the resident was. The FEC did not state if she told anyone about what she witnessed. During an interview on 5/24/2024 at 6:15 p.m. with CNA E and CNA F both reported they saw COTA D take Resident #1 out to eat several times on weekends. They reported they told RN G the COTA was taking the resident out to dinner. During an interview on 5/24/2024 at 6:18 p.m. with RN G she reported she saw COTA D dressed in a suit, Resident #1 had make-up on and was wearing a dress, and the COTA took the resident out to eat. RN G stated she saw COTA take the resident out two times and she never saw the COTA enter the resident's room. RN G stated she spoke to Resident #1, and the resident was excited, and giddy that COTA D was paying attention to her. The RN stated the resident would sign herself out. RN G asked Resident #1 if there was more than a friendship between the therapist and resident, and the resident stated they were just friends. RN G stated she never told anyone because she thought administration knew he was taking her out to eat. During an interview on 5/22/2024 at 1:39 p.m. with the SW, she stated she was not aware of any inappropriate behavior by COTA D until after everything came out. 2. Record review of Resident #2's face sheet dated 5/24/2024 reflected the resident was a [AGE] year-old female who was initially admitted on [DATE], and a readmitted [DATE]. Resident #2 had diagnoses which included cerebral infarction (a brain injury caused by disruption of blood flow to the brain), hemiplegia (severe or complete paralysis on one side of the body) and hemiparesis (one-sided muscle weakness because of disruptions in the brain, spinal cord, or the nerves that connect the affected muscles) following cerebral infarction affecting right dominant side, major depressive disorder major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and central pain syndrome (a rare neurological condition that causes chronic pain due to damage to the central nervous system). Record review of Resident #2's annual MDS assessment, dated 5/2/2024, reflected the resident had a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #2's care plan reflected the resident was receiving pain medication therapy which included Gabapentin and Baclofen. Record review of Resident #2's Quarterly MDS assessment, dated 2/7/2024, reflected the resident had an occupational therapy start date of 2/1/2024. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1, she stated Resident #2 told her COTA D would take Resident #2's pants off during occupational therapy. During a telephone interview on 5/22/2024 at 2:20 p.m. with CNA A, she reported one day she noticed Resident #2's door was shut, and she thought that was odd because the resident always left her door open. CNA A stated she knocked, and then opened the door and saw COTA D sitting in the resident's room with his hand on the resident's leg and they were watching television. The CNA explained she saw the COTA was sitting in a chair next to the bed and the resident was in bed. CNA A stated Resident #2 was not wearing any pants and only her brief and a shirt. The CNA stated she could only see COTA D's one hand on her knee and did not know where his other hand was. CNA A stated the COTA and resident did not say anything, and she apologized and walked out. CNA A stated she thought it was a few months ago. The CNA stated she spoke to Resident #2 later and asked her if she felt uncomfortable with COTA D and she said no. The CNA stated she did not tell anyone until recently when questioned about COTA D by administrative staff. During an interview on 5/22/2024 at 1:56 p.m. with CNA B she stated Resident #2 told her whenever she and COTA D had a therapy session, he would take off her pants. Resident #2 told her not to tell anyone. CNA B stated when COTA D started doing therapy sessions with Resident #2 in the therapy room, the resident got made at the CNA, thinking she had told someone. The CNA stated she did not tell anyone about COTA D removing Resident #2's pants because the resident asked her not to. During an interview on 5/24/2024 at 11:14 a.m. with Resident #2 she reported she worked with COTA D a couple of days. The resident reported during their therapy sessions he was working with her legs. Resident #2 stated COTA D took off her pants when he was working with her. The resident stated she was wearing a brief. Resident #2 reported she did not ask the COTA why he removed her pants. Resident #2 stated the COTA would touch and rub her legs, but he never explained anything while he worked with her. Resident #2 stated, it made her feel terrible when COTA D took off her pants. Resident #2 stated on one occasion a CNA walked in when she was working with COTA D and her pants were off. The resident stated the CNA did not say anything. Resident #2 stated the COTA had not touched her anywhere else but her legs when he worked with her. 3. Record review of Resident #3's face sheet, dated 5/24/2024, reflected the resident was a [AGE] year-old female with an original admitted [DATE], a readmitted [DATE], and a discharge date of [DATE]. Resident #3's had diagnoses which included hepatorenal syndrome (a life-threatening condition that occurs when the kidneys of someone with advanced liver disease begin to fail), hypertension (high blood pressure), (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (frequent feelings of fear and worry that is intense and excessive), and chronic pain. Record review of Resident #3's 5-day MDS assessment, dated 1/17/2024, reflected the resident began occupational therapy on 1/24/2024 and received therapy 4 days a week. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator he reported around mid-February, he learned a previous resident, Resident #3, was at the hospital, was being released soon, and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not the facility. The Administrator reported when Resident #3 stayed at the facility before she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident had confided in her that she did not want to return to the facility because of COTA D and he had visited her home a couple of times after she discharged , and he was handsy (touch other people in a way that is inappropriate or unwanted). The Administrator reported she assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D gave her thong underwear one of the times he visited her home. During an interview on 5/24/2024 at 4:10 p.m. with the Marketing Director she reported she was a family friend of Resident #3, and the resident told her about COTA D being inappropriate with her on her previous visit. The Marketing Director stated Resident #3 initially enjoyed the attention COTA D was giving her but when the resident felt the COTA wanted more than a friendship, she felt uncomfortable. During an interview on 5/27/2024 at 10:01 a.m. with Resident #3, she reported while she was at the facility on her previous visit, she received occupational therapy by COTA D. Resident #3 stated when COTA D was massaging her back, he began fondling her private area and COTA D told Resident #3, I am gonna tap (slang for sexual intercourse) that one day. The resident stated she did not report it to the facility because she was afraid to. Resident #3 stated COTA D was tall at 6'4'' and a big man, and she was afraid of him so when he asked for her telephone number when she was ready to discharge, she gave it to him. Resident #3 reported when she was back in the community living at her apartment COTA D called her and said he was coming over to see that her home was handicap accessible and she did not know what to say. Resident #3 stated she had gone out to eat with the COTA at that time because he insisted, she go. That was when he came into her apartment the first time, stating he needed to check that her apartment was handicap accessible. The resident stated COTA D came over to her apartment, but the resident stated she did not know how he got her address. Resident #3 stated the COTA came over to her apartment a second time and brought her a gift, thong underwear. The resident stated COTA D wanted her to wear the underwear in front of him and initially she said no but she felt intimidated because she was by herself, so she wore the underwear in front of him and then changed and told the COTA to leave. Resident #3 stated COTA D showed up a third time, wanted the resident to sit on his lap but she refused so he left. Resident #3 stated COTA D never showed up again. Resident #3 stated she did not know what to do when he wanted to come over. 4. Record review of Resident #4's face sheet dated 5/24/2024 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses that included dementia without behavioral disturbance, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (high blood pressure), and pain. Record review of Resident #4's Quarterly MDS assessment, dated 2/19/2024, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact and no mood or behavioral concerns. Record review of Resident #4's May 2024 Consolidated Physician Orders reflected the resident was discharged from occupational therapy services on 1/26/2024. Review of Record review of Resident #4's care plan initiated 8/11/2017 reflected the resident received pain medication which included Tramadol and gabapentin. During an interview on 5/23/2024 at 11:03 p.m., Resident #4 stated she received therapy at the facility, and she did not especially want it. Resident #4 stated she had a male therapist who made her feel uncomfortable. She provided COTA D's first name and gave a brief description. Resident #4 stated during a therapy session, her back was hurting and COTA D pulled her pants down a bit to put some Bio-freeze on her buttock, and she thought this was odd. The resident reported this only happened once. Resident #4 stated she told an unidentified staff member about the incident and the staff member told her to wait and see if he does it again. Resident #4 stated she did not recall who the staff member was. The resident stated the incident happened over 6 months ago in the therapy room while she was lying on the table. She did not report if anyone else was present. During an interview on 5/23/2024 at 12:43 p.m., the Administrator stated Resident #4 never said anything when they interviewed residents for concerns related to abuse and neglect. Record review of Resident #5's face sheet dated 5/24/2024 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should), shortness of breath (feeling you cannot get enough air into your lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus without complications (when the pancreas does not make enough insulin), and unspecified pain. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #5's May 2024 Concentrated Physician Orders reflected the resident had an order for Lidocaine patch and gabapentin for pain and she was discharged from occupational therapy on 4/2/2024. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident received occupational therapy with a start date of 11/10/2023 and an end date on 1/5/2024. During an observation and interview on 5/24/2024 at 7:35 p.m. with Resident #5 revealed she received occupational therapy from COTA D. the Resident #5 stated while COTA D was rubbing her back, he began rubbing her buttock and intergluteal cleft (the posterior deep midline groove in the gluteal region that separates the buttocks). Resident #5 showed the region on her body where the therapist had rubbed her. The resident's voice got louder as she talked about it. Resident #5 stated it only happened one time. The resident stated she told the Administrator about it. During an interview on 5/24/2024 at 8:02 p.m. with the Administrator he stated they interviewed Resident #5 regarding abuse and neglect and the resident never reported COTA D touching her inappropriately. The Administrator went on to say he did not recall Resident #5 telling him about the incident and stated he would have remembered something like it. During an interview on 5/22/2024 at 12:30 p.m. with the DOR she stated she began working at the facility PRN in June 2023, and became the DOR in July 2023. The DOR reported COTA D was already working at the facility when she started. The DOR stated she and several members of management had verbally in-serviced the COTA about following each of the residents Plan of Care that was established by the OT when the resident was evaluated. The DOR reported COTA D was reporting additional hours and provided other treatments, including taking Resident #1 out for lunch to meet with her family several times, not prescribed on the Plan of Care, which was outside his scope of practice. The DOR stated COTA D would follow the Plan of Care for a while but then would go back to providing treatment outside the COTA's scope of practice. The DOR reported Resident #1 spoke to her about going on a weekend pass to see COTA D's new house but knew the Administrator had already spoken to the COTA regarding rumors the COTA and Resident #1 had planned to live together after she discharged . The DOR stated Resident #1 later reported they were having a consensual relationship, but he was gaslighting (a form of emotional abuse that causes the victim to question their own feelings) the resident. The DOR reported sometime in August (she could not recall the date), during a weekend, she witnessed COTA D was all dressed up and pushing Resident #1 in her wheelchair out of the facility. The DOR reported she told the Administrator, and the DOR was off the clock at the time. The DOR stated COTA D was fired on 3/4/2024. During a telephone interview on 5/22/2024 at 3:57 a.m. with COTA D, he reported he had been a COTA for [AGE] years and began working at the facility on May 22, 2023. COTA D stated he gave statements to the licensing board and the facility should have a copy. The COTA stated he would not say any names of the residents he worked with and anything about the incidents. He stated when he was working at the facility, he would work 8, 9, or 10 hours a day. COTA D stated some residents were bedbound so therapy would begin in their room and as they progressed, they went to the gym. The COTA reported there was a restaurant about two blocks away from the facility and he would accompany the residents with their families for integration back into society and it was part of the residents' therapy treatment. COTA D stated no resident had ever been to his home. The COTA stated as part of COTA treatment they did home evaluations, home assessments, and home health. COTA D stated he did several home evaluations and house assessments during his career. The COTA reported they did not have relationships with their residents. COTA D stated sometimes residents were drawn by skilled, knowledgeable healthcare workers. COTA D stated he recalled everyone gave a resident a gift and his gift were a pair of shorts. The COTA stated the resident was female and she would wear shorts to therapy. COTA D stated that I do not have any relationship with residents. When the COTA was asked if he was working again, he stated, You do not need to worry about his personal business. During a telephone interview on 5/24/2024 at 2:54 p.m. with the Medical Director she reported she was made aware of the IJ. The Medical Director reported they also had a QAPI after the IJ was called. The Medical Director stated no residents were identified when she spoke to the Administrator and during QAPI. The Medical Director reported Resident #2 was one of her residents she saw at the facility and was not aware of the incident. The Medical Director noted she did have another physician that took calls for her and assisted with the residents at the facility, and he may have been informed about the incident with Resident #2. The Medical Director stated she would follow up with Resident #2 herself to see that she was doing okay. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator, he reported on 10/12/2023 he spoke to COTA D about rumors the COTA and Resident #1 were going to move in together when she was discharged . The Administrator reported COTA D denied the allegation and stated they were just friends. The Administrator reported he discussed professional boundaries with the COTA and reviewed the Code of Ethics between a therapist and resident. The Administrator also had COTA D sign a written warning letter to confirm he was instructed and understood ethical boundaries. The Administrator stated he then went to talk to Resident #1 about the rumor and at that time Resident #1 was asking about going out on pass to see COTA D's new home. The resident reported to the Administrator she and her parents were going to see COTA D's house he recently purchased. The Administrator stated he questioned Resident #1 about the rumors she was planning to move in with COTA D, and the resident denied the relationship and stated they were just friends. The Administrator reported Resident #1 never went out on pass to see the COTA's house. The Administrator stated at the time he believed COTA D was telling the truth, He was so convincing by the way he responded, and other residents reported how much they liked him. The Administrator stated the COTA was also disciplined for taking extra-long time with each treatment he was providing, running more labor hours per resident. The Administrator reported it eventually got better after several talks with COTA D. The Administrator reported he discovered Resident #1 and COTA D had a romantic relationship on February 29, 2024. The Administrator reported initially around mid-February, he learned a previous resident, Resident #3, was at the hospital and being released soon and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not to their facility. The Administrator stated when Resident #3 stayed at the facility before, she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident confided in her that she did not want to return to the facility because of COTA D and that he had visited her home a couple of times after she discharged , and he was handsy (touching other people in a way that is inappropriate or unwanted). The Administrator reported he assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D had given her thong underwear one of the times he visited her home. The Administrator reported they began interviewing all residents on abuse and neglect, asking the residents if they ever had any issues with staff, and that was when Resident #1 reported she had a sexual relationship with COTA D. The Administrator also spoke to staff and learned that CNA A walked into Resident #2's room and the COTA was in the room and the resident was not wearing pants. The Administrator also reported he learned Resident #2 told CNA B that COTA D took her pants off during therapy. The Administrator reported no other residents reported an incident with COTA D. The Administrator stated he made a referral to the OT/COTA licensing board, but he did not receive copies of the COTA's statement to the board) Record review of the facility's policy titled, Abuse/Neglect, revised 10/14/2022, reflected, Resident's should not be subject to abuse by anyone, including, but not limited to facility staff. 4. Sexual Abuse-non-consensual sexual contact of any type with a resident. C. Prevention, 3. All reports of abuse or suspicion of abuse/neglect or potential criminal behavior will be investigated as per facility policy and 5. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. D. Identification, Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and /or Adult Protective Services. E. Investigation, The Administrator or Risk Management Department will be responsible for investigation and reporting cases to Health and Human Services Commission. F. Protection, The facility will take necessary measures to protect residents .during and following an abuse, neglect, and exploitation, misappropriation of residents or misappropriation of resident property investigation. Record review of the Occupational Therapy Code of Ethics and Ethics Standards (2010) provided by the facility, under the heading, Nonmaleficence, reflected Occupational therapy personnel shall: C. Avoid relationships that exploit the recipient of services . physically, emotionally, psychologically, financially, socially, or in any other manner that conflicts or interferes with professional judgement and objectivity, .D. Avoid engaging in any sexual relationship or [TRUNCATED]

Based on observation, interview, and record review, the facility failed to follow their policies and procedures to prevent mistreatment, abuse, neglect, and exploitation of a resident, and misappropriatoions of residents property for 4 of 9 residents (Residents #1, #2, #3, #4, and #5) reviewed for abuse. 1. The facility failed to follow their plocies and procedures to investigate and report to state office when they received allegations that COTA D was having a relationship Relationship with COTA D. COTA D had intercourse with Resident #1 in the resident's room after the resident was on the therapist's caseload. 2. The facility failed to protect Resident #2 when CNA A witnessed COTA D was in the resident's room and she was not wearing pants for her therapy treatment. CNA B was also informed by the resident that COTA D removed her pants when providing therapy. 3. The facility failed to prevent COTA D from touching Resident #4 and Resident #5's buttocks while rubbing their back during their therapy session. 4. The facility failed to prevent COTA D from touching Resident #3's buttock and genitalia while rubbing her back during her therapy session. An Immediate Jeopardy (IJ) was identified on 5/23/2024. The IJ template was provided to the facility on [DATE] at 4:43 p.m. While the IJ was removed on 5/25/2024, the facility remained out of compliance at a scope of pattern, with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of sexual abuse from facility staff. Findings include: 1. Record review of Resident #1's face sheet, dated 5/24/2024, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and had diagnoses that included hypertensive heart disease with heart failure (heart problems caused by long-term heart pressure), morbid obesity due to excessive calories (weight that is 80 to 100 pounds above their ideal body weight), body mass index (a ratio of your weight to your height) of 70 or greater, type 2 diabetes mellitus (when the pancreas does not make insulin), sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (frequent feelings of fear and worry that is intense and excessive). Record review of Resident #1's care plan, initiated 11/22/2021, reflected the resident had a potential to exhibit withdrawal from activities and socialization due to health condition, physical, and mental limitations, problems, concerns, etc. The care plan interventions included the Social Worker providing support and verbalization of feelings, thoughts, needs, problems, and concerns. Record review of Resident #1's annual MDS assessment, dated 12/22/2023 reflected a BIMS score was 15, which indicated the resident was cognitively intact. Resident #1 had no mood or behavioral concerns and used a walker and wheelchair for ambulation. Record review of Resident #1's May 2024 Consolidated Physician Orders reflected an order, with a start date of 10/12/2023, that the resident had Occupational Therapy 4 times a week for 30 days. Record review of the Facility Incident Report, dated 2/29/2024, reflected Resident #1 reported to the facility during the months of September and October 2023, COTA D had gaslight me and groomed me for a relationship and she realized he had been taking advantage of her. The report reflected COTA D had intercourse with Resident #1 in the resident's room. Record review of the Police Report Case Identification Number 24-00293, dated 2/29/2024, reflected the police were informed by the facility of COTA D's inappropriate sexual behavior with residents. Record review of COTA D's personnel file revealed the COTA was hired on 5/22/2024, suspended on 2/21/2024, and his employment was terminated on 2/28/2024. The personnel file revealed COTA D was given a verbal warning on 10/12/2024 regarding following professional boundaries because of a rumor that he and Resident #1 were planning to move in together after the resident was discharged . On 1/8/2024 COTA D was given a written warning because he was not following the residents plan of care, Medicare guidelines for documentation and he was working overtime without approval. A disciplinary action form initiated 2/27/2024 and signed on 2/28/2024 revealed COTA D was terminated due to inappropriate relations and unprofessional conduct with facility a facility resident and former resident. During an interview on 5/22/2024 at 10:27 a.m. with the PNP she stated the SW referred Resident #1 when information came out about the resident's intimate relationship with COTA D. The PNP stated the resident was vulnerable when COTA D began taking interest in the resident. The PNP reported as their relationship progressed, COTA D told Resident #1 he could provide her a stable relationship and a home for them to live together. The PNP stated Resident #1 expressed increased depression, so she increased the resident's antidepressant dosage. The PNP stated Resident #1 scored high on her anxiety assessment, but the resident was already on an anti-anxiety medication, and the resident did not appear anxious during their meeting. The PNP reported she could not say for sure if the incident made the resident mentally upset, and because the resident was already depressed before the incident, the PNP stated it was difficult to gauge what emotional impact the incident had on the resident. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1 she stated she began receiving occupational therapy with COTA D and continued having a relationship until her surgery in November 2023. Resident #1 stated the COTA started grooming me from the beginning, telling the resident she was a beautiful woman and how great she would look when she lost weight (Resident #1 was scheduled for Lap band surgery in November 2023). Resident #1 reported when she first began working with COTA D, she was engaged to another male living in the community and the COTA was aware of their relationship. Resident #1 stated when she began having problems with her relationship with her fiancee, she would confide in COTA D, and he was supportive. Resident #1 stated she was in a vulnerable state when their romantic relationship began in September 2023. She reported COTA D was her Knight in Shining [NAME], telling her he bought a house for them to move in together and he would paint pictures of a fabulous life and how he would take care of me. Resident #1 reported at that time the COTA was taking her out to eat in the evenings at a restaurant nearby and he would take her to lunch to meet her family, who were visiting from out of town. Resident #1 stated at first COTA D did not stay when he took her to see her family, but a short time later he began joining them for lunch. Resident #1 also reported it was in September 2023 that they had intercourse in the resident's room. Resident #1 reported it was late in the evening, and COTA D checked that all the department heads left for the day. Resident #1 reported they only had intercourse one time. Resident #1 stated in November 2023, their relationship ended, however, the COTA would still kiss her and rubbed her buttocks during her cryotherapy (or cold therapy, where low temperatures are used as part of the therapy treatment to relieve muscle pain or swelling after surgery). Resident #1 reported she found out later that COTA D told her fiancee he never had any intention of the resident moving in with him, and he only said this to motivate her in therapy. The resident reported staff would see them together, but COTA D never did anything inappropriate in front of them. Resident #1 reported the Administrator had asked her in September 2023 if she and the COTA had a serious relationship and she told the Administrator they were just friends. She also reported the Administrator asked her again about a relationship between her and COTA D in November 2023, and she told him no. The resident reported by that time it was over and she was telling the truth. Resident #1 stated only one resident asked her if she was having a relationship with COTA D. Resident #1 reported COTA D was still calling her after he no longer worked for the facility, and she told him to stop calling her and he blocked his phone number on her cell phone. During an interview on 5/22/2024 at 1:56 p.m. with CNA B, she stated she saw COTA D take Resident #1 to the nearby restaurant and the COTA stated they were going out to eat with her family and it was part of her therapy. The CNA stated she never saw COTA D take any other resident outside of the facility. CNA B stated she thought it was odd the COTA was taking the resident out to eat but she never told anyone. CNA B could not provide a reason why she did not tell anyone. During an observation and interview on 5/22/2024 at 2:55 p.m. with HA C she stated after the first State Surveyor went to the facility to investigate the incident, the CNA the resident was not herself and appeared more depressed now that she began telling others about her past relationship with COTA D. During a telephone interview on 5/24/2024 at 3:00 p.m. with Resident #1's FEC she reported she first met COTA D in September 2023 at the facility. The FEC stated the COTA was cordial but felt conversations with the COTA were forced conversations. Resident #1's FEC stated when they ate with Resident #1 and COTA D, the COTA stated he was looking for wife-material, referring to the resident. The FEC stated at the time Resident #1 had another boyfriend who lived in the community but stated COTA D promised to move her in with him in his new home. The FEC stated they had lunch with the COTA at least 4 times. The FEC stated she recalled another incident when she saw COTA D working with another resident, the COTA helped the resident up from the chair holding her buttock instead of under the resident's arms. Resident #1's FEC stated she could not recall when this occurred, and she did not know who the resident was. The FEC did not state if she told anyone about what she witnessed. During an interview on 5/24/2024 at 6:15 p.m. with CNA E and CNA F both reported they saw COTA D take Resident #1 out to eat several times on weekends. They reported they told RN G the COTA was taking the resident out to dinner. During an interview on 5/24/2024 at 6:18 p.m. with RN G she reported she saw COTA D dressed in a suit, Resident #1 had make-up on and was wearing a dress, and the COTA took the resident out to eat. RN G stated she saw COTA take the resident out two times and she never saw the COTA enter the resident's room. RN G stated she spoke to Resident #1, and the resident was excited, and giddy that COTA D was paying attention to her. The RN stated the resident would sign herself out. RN G asked Resident #1 if there was more than a friendship between the therapist and resident, and the resident stated they were just friends. RN G stated she never told anyone because she thought administration knew he was taking her out to eat. During an interview on 5/22/2024 at 1:39 p.m. with the SW, she stated she was not aware of any inappropriate behavior by COTA D until after everything came out. 2. Record review of Resident #2's face sheet dated 5/24/2024 reflected the resident was a [AGE] year-old female who was initially admitted on [DATE], and a readmitted [DATE]. Resident #2 had diagnoses which included cerebral infarction (a brain injury caused by disruption of blood flow to the brain), hemiplegia (severe or complete paralysis on one side of the body) and hemiparesis (one-sided muscle weakness because of disruptions in the brain, spinal cord, or the nerves that connect the affected muscles) following cerebral infarction affecting right dominant side, major depressive disorder major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and central pain syndrome (a rare neurological condition that causes chronic pain due to damage to the central nervous system). Record review of Resident #2's annual MDS assessment, dated 5/2/2024, reflected the resident had a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #2's care plan reflected the resident was receiving pain medication therapy which included Gabapentin and Baclofen. Record review of Resident #2's Quarterly MDS assessment, dated 2/7/2024, reflected the resident had an occupational therapy start date of 2/1/2024. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1, she stated Resident #2 told her COTA D would take Resident #2's pants off during occupational therapy. During a telephone interview on 5/22/2024 at 2:20 p.m. with CNA A, she reported one day she noticed Resident #2's door was shut, and she thought that was odd because the resident always left her door open. CNA A stated she knocked, and then opened the door and saw COTA D sitting in the resident's room with his hand on the resident's leg and they were watching television. The CNA explained she saw the COTA was sitting in a chair next to the bed and the resident was in bed. CNA A stated Resident #2 was not wearing any pants and only her brief and a shirt. The CNA stated she could only see COTA D's one hand on her knee and did not know where his other hand was. CNA A stated the COTA and resident did not say anything, and she apologized and walked out. CNA A stated she thought it was a few months ago. The CNA stated she spoke to Resident #2 later and asked her if she felt uncomfortable with COTA D and she said no. The CNA stated she did not tell anyone until recently when questioned about COTA D by administrative staff. During an interview on 5/22/2024 at 1:56 p.m. with CNA B she stated Resident #2 told her whenever she and COTA D had a therapy session, he would take off her pants. Resident #2 told her not to tell anyone. CNA B stated when COTA D started doing therapy sessions with Resident #2 in the therapy room, the resident got made at the CNA, thinking she had told someone. The CNA stated she did not tell anyone about COTA D removing Resident #2's pants because the resident asked her not to. During an interview on 5/24/2024 at 11:14 a.m. with Resident #2 she reported she worked with COTA D a couple of days. The resident reported during their therapy sessions he was working with her legs. Resident #2 stated COTA D took off her pants when he was working with her. The resident stated she was wearing a brief. Resident #2 reported she did not ask the COTA why he removed her pants. Resident #2 stated the COTA would touch and rub her legs, but he never explained anything while he worked with her. Resident #2 stated, it made her feel terrible when COTA D took off her pants. Resident #2 stated on one occasion a CNA walked in when she was working with COTA D and her pants were off. The resident stated the CNA did not say anything. Resident #2 stated the COTA had not touched her anywhere else but her legs when he worked with her. 3. Record review of Resident #3's face sheet, dated 5/24/2024, reflected the resident was a [AGE] year-old female with an original admitted [DATE], a readmitted [DATE], and a discharge date of [DATE]. Resident #3's had diagnoses which included hepatorenal syndrome (a life-threatening condition that occurs when the kidneys of someone with advanced liver disease begin to fail), hypertension (high blood pressure), (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (frequent feelings of fear and worry that is intense and excessive), and chronic pain. Record review of Resident #3's 5-day MDS assessment, dated 1/17/2024, reflected the resident began occupational therapy on 1/24/2024 and received therapy 4 days a week. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator he reported around mid-February, he learned a previous resident, Resident #3, was at the hospital, was being released soon, and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not the facility. The Administrator reported when Resident #3 stayed at the facility before she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident had confided in her that she did not want to return to the facility because of COTA D and he had visited her home a couple of times after she discharged , and he was handsy (touch other people in a way that is inappropriate or unwanted). The Administrator reported she assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D gave her thong underwear one of the times he visited her home. During an interview on 5/24/2024 at 4:10 p.m. with the Marketing Director she reported she was a family friend of Resident #3, and the resident told her about COTA D being inappropriate with her on her previous visit. The Marketing Director stated Resident #3 initially enjoyed the attention COTA D was giving her but when the resident felt the COTA wanted more than a friendship, she felt uncomfortable. During an interview on 5/27/2024 at 10:01 a.m. with Resident #3, she reported while she was at the facility on her previous visit, she received occupational therapy by COTA D. Resident #3 stated when COTA D was massaging her back, he began fondling her private area and COTA D told Resident #3, I am gonna tap (slang for sexual intercourse) that one day. The resident stated she did not report it to the facility because she was afraid to. Resident #3 stated COTA D was tall at 6'4'' and a big man, and she was afraid of him so when he asked for her telephone number when she was ready to discharge, she gave it to him. Resident #3 reported when she was back in the community living at her apartment COTA D called her and said he was coming over to see that her home was handicap accessible and she did not know what to say. Resident #3 stated she had gone out to eat with the COTA at that time because he insisted, she go. That was when he came into her apartment the first time, stating he needed to check that her apartment was handicap accessible. The resident stated COTA D came over to her apartment, but the resident stated she did not know how he got her address. Resident #3 stated the COTA came over to her apartment a second time and brought her a gift, thong underwear. The resident stated COTA D wanted her to wear the underwear in front of him and initially she said no but she felt intimidated because she was by herself, so she wore the underwear in front of him and then changed and told the COTA to leave. Resident #3 stated COTA D showed up a third time, wanted the resident to sit on his lap but she refused so he left. Resident #3 stated COTA D never showed up again. Resident #3 stated she did not know what to do when he wanted to come over. 4. Record review of Resident #4's face sheet dated 5/24/2024 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses that included dementia without behavioral disturbance, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (high blood pressure), and pain. Record review of Resident #4's Quarterly MDS assessment, dated 2/19/2024, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact and no mood or behavioral concerns. Record review of Resident #4's May 2024 Consolidated Physician Orders reflected the resident was discharged from occupational therapy services on 1/26/2024. Review of Record review of Resident #4's care plan initiated 8/11/2017 reflected the resident received pain medication which included Tramadol and gabapentin. During an interview on 5/23/2024 at 11:03 p.m., Resident #4 stated she received therapy at the facility, and she did not especially want it. Resident #4 stated she had a male therapist who made her feel uncomfortable. She provided COTA D's first name and gave a brief description. Resident #4 stated during a therapy session, her back was hurting and COTA D pulled her pants down a bit to put some Bio-freeze on her buttock, and she thought this was odd. The resident reported this only happened once. Resident #4 stated she told an unidentified staff member about the incident and the staff member told her to wait and see if he does it again. Resident #4 stated she did not recall who the staff member was. The resident stated the incident happened over 6 months ago in the therapy room while she was lying on the table. She did not report if anyone else was present. During an interview on 5/23/2024 at 12:43 p.m., the Administrator stated Resident #4 never said anything when they interviewed residents for concerns related to abuse and neglect. Record review of Resident #5's face sheet dated 5/24/2024 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should), shortness of breath (feeling you cannot get enough air into your lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus without complications (when the pancreas does not make enough insulin), and unspecified pain. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #5's May 2024 Concentrated Physician Orders reflected the resident had an order for Lidocaine patch and gabapentin for pain and she was discharged from occupational therapy on 4/2/2024. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident received occupational therapy with a start date of 11/10/2023 and an end date on 1/5/2024. During an observation and interview on 5/24/2024 at 7:35 p.m. with Resident #5 revealed she received occupational therapy from COTA D. the Resident #5 stated while COTA D was rubbing her back, he began rubbing her buttock and intergluteal cleft (the posterior deep midline groove in the gluteal region that separates the buttocks). Resident #5 showed the region on her body where the therapist had rubbed her. The resident's voice got louder as she talked about it. Resident #5 stated it only happened one time. The resident stated she told the Administrator about it. During an interview on 5/24/2024 at 8:02 p.m. with the Administrator he stated they interviewed Resident #5 regarding abuse and neglect and the resident never reported COTA D touching her inappropriately. The Administrator went on to say he did not recall Resident #5 telling him about the incident and stated he would have remembered something like it. During an interview on 5/22/2024 at 12:30 p.m. with the DOR she stated she began working at the facility PRN in June 2023, and became the DOR in July 2023. The DOR reported COTA D was already working at the facility when she started. The DOR stated she and several members of management had verbally in-serviced the COTA about following each of the residents Plan of Care that was established by the OT when the resident was evaluated. The DOR reported COTA D was reporting additional hours and provided other treatments, including taking Resident #1 out for lunch to meet with her family several times, not prescribed on the Plan of Care, which was outside his scope of practice. The DOR stated COTA D would follow the Plan of Care for a while but then would go back to providing treatment outside the COTA's scope of practice. The DOR reported Resident #1 spoke to her about going on a weekend pass to see COTA D's new house but knew the Administrator had already spoken to the COTA regarding rumors the COTA and Resident #1 had planned to live together after she discharged . The DOR stated Resident #1 later reported they were having a consensual relationship, but he was gaslighting (a form of emotional abuse that causes the victim to question their own feelings) the resident. The DOR reported sometime in August (she could not recall the date), during a weekend, she witnessed COTA D was all dressed up and pushing Resident #1 in her wheelchair out of the facility. The DOR reported she told the Administrator, and the DOR was off the clock at the time. The DOR stated COTA D was fired on 3/4/2024. During a telephone interview on 5/22/2024 at 3:57 a.m. with COTA D, he reported he had been a COTA for [AGE] years and began working at the facility on May 22, 2023. COTA D stated he gave statements to the licensing board and the facility should have a copy. The COTA stated he would not say any names of the residents he worked with and anything about the incidents. He stated when he was working at the facility, he would work 8, 9, or 10 hours a day. COTA D stated some residents were bedbound so therapy would begin in their room and as they progressed, they went to the gym. The COTA reported there was a restaurant about two blocks away from the facility and he would accompany the residents with their families for integration back into society and it was part of the residents' therapy treatment. COTA D stated no resident had ever been to his home. The COTA stated as part of COTA treatment they did home evaluations, home assessments, and home health. COTA D stated he did several home evaluations and house assessments during his career. The COTA reported they did not have relationships with their residents. COTA D stated sometimes residents were drawn by skilled, knowledgeable healthcare workers. COTA D stated he recalled everyone gave a resident a gift and his gift were a pair of shorts. The COTA stated the resident was female and she would wear shorts to therapy. COTA D stated that I do not have any relationship with residents. When the COTA was asked if he was working again, he stated, You do not need to worry about his personal business. During a telephone interview on 5/24/2024 at 2:54 p.m. with the Medical Director she reported she was made aware of the IJ. The Medical Director reported they also had a QAPI after the IJ was called. The Medical Director stated no residents were identified when she spoke to the Administrator and during QAPI. The Medical Director reported Resident #2 was one of her residents she saw at the facility and was not aware of the incident. The Medical Director noted she did have another physician that took calls for her and assisted with the residents at the facility, and he may have been informed about the incident with Resident #2. The Medical Director stated she would follow up with Resident #2 herself to see that she was doing okay. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator, he reported on 10/12/2023 he spoke to COTA D about rumors the COTA and Resident #1 were going to move in together when she was discharged . The Administrator reported COTA D denied the allegation and stated they were just friends. The Administrator reported he discussed professional boundaries with the COTA and reviewed the Code of Ethics between a therapist and resident. The Administrator also had COTA D sign a written warning letter to confirm he was instructed and understood ethical boundaries. The Administrator stated he then went to talk to Resident #1 about the rumor and at that time Resident #1 was asking about going out on pass to see COTA D's new home. The resident reported to the Administrator she and her parents were going to see COTA D's house he recently purchased. The Administrator stated he questioned Resident #1 about the rumors she was planning to move in with COTA D, and the resident denied the relationship and stated they were just friends. The Administrator reported Resident #1 never went out on pass to see the COTA's house. The Administrator stated at the time he believed COTA D was telling the truth, He was so convincing by the way he responded, and other residents reported how much they liked him. The Administrator stated the COTA was also disciplined for taking extra-long time with each treatment he was providing, running more labor hours per resident. The Administrator reported it eventually got better after several talks with COTA D. The Administrator reported he discovered Resident #1 and COTA D had a romantic relationship on February 29, 2024. The Administrator reported initially around mid-February, he learned a previous resident, Resident #3, was at the hospital and being released soon and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not to their facility. The Administrator stated when Resident #3 stayed at the facility before, she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident confided in her that she did not want to return to the facility because of COTA D and that he had visited her home a couple of times after she discharged , and he was handsy (touching other people in a way that is inappropriate or unwanted). The Administrator reported he assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D had given her thong underwear one of the times he visited her home. The Administrator reported they began interviewing all residents on abuse and neglect, asking the residents if they ever had any issues with staff, and that was when Resident #1 reported she had a sexual relationship with COTA D. The Administrator also spoke to staff and learned that CNA A walked into Resident #2's room and the COTA was in the room and the resident was not wearing pants. The Administrator also reported he learned Resident #2 told CNA B that COTA D took her pants off during therapy. The Administrator reported no other residents reported an incident with COTA D. The Administrator stated he made a referral to the OT/COTA licensing board, but he did not receive copies of the COTA's statement to the board) Record review of the facility's policy titled, Abuse/Neglect, revised 10/14/2022, reflected, Resident's should not be subject to abuse by anyone, including, but not limited to facility staff. 4. Sexual Abuse-non-consensual sexual contact of any type with a resident. C. Prevention, 3. All reports of abuse or suspicion of abuse/neglect or potential criminal behavior will be investigated as per facility policy and 5. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. D. Identification, Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and /or Adult Protective Services. E. Investigation, The Administrator or Risk Management Department will be responsible for investigation and reporting cases to Health and Human Services Commission. F. Protection, The facility will take necessary measures to protect residents .during and following an abuse, neglect, and exploitation, misappropriation of residents or misappropriation of resident property investigation. Record review of the Occupational Therapy Code of Ethics and Ethics Standards (2010) provided by the facility, under the heading, Nonmaleficence, reflected Occupational thera[TRUNCATED]

Based on observation, interview and record review the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychological well-being of each resident in that: The facility failed to ensure that residents were free from abuse for 5 (Residents #1, 2, 3, 4, 5)) of 9 residents reviewed for abuse. The facility failed to follow their policy and procedure for investigating allegations of abuse. The Administrator was first alerted that COTA D and Resident #1 were having a relationship beyond resident and therapist on 10/ 2024 but failed to further investigate and report the allegation. The facility failed to implement interventions to ensure Resident #1 was safe after receiving an allegation that COTA D was having a relationship beyond therapist and resident. An Immediate Jeopardy (IJ) was identified on 5/23/2024. The IJ template was provided to the facility on [DATE] at 4:43 p.m. While the IJ was removed on 5/25/2024, the facility remained out of compliance at a scope of pattern, with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of sexual abuse from facility staff. Findings include: 1. Record review of Resident #1's face sheet, dated 5/24/2024, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and had diagnoses that included hypertensive heart disease with heart failure (heart problems caused by long-term heart pressure), morbid obesity due to excessive calories (weight that is 80 to 100 pounds above their ideal body weight), body mass index (a ratio of your weight to your height) of 70 or greater, type 2 diabetes mellitus (when the pancreas does not make insulin), sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (frequent feelings of fear and worry that is intense and excessive). Record review of Resident #1's care plan, initiated 11/22/2021, reflected the resident had a potential to exhibit withdrawal from activities and socialization due to health condition, physical, and mental limitations, problems, concerns, etc. The care plan interventions included the Social Worker providing support and verbalization of feelings, thoughts, needs, problems, and concerns. Record review of Resident #1's annual MDS assessment, dated 12/22/2023 reflected a BIMS score was 15, which indicated the resident was cognitively intact. Resident #1 had no mood or behavioral concerns and used a walker and wheelchair for ambulation. Record review of Resident #1's May 2024 Consolidated Physician Orders reflected an order, with a start date of 10/12/2023, that the resident had Occupational Therapy 4 times a week for 30 days. Record review of the Facility Incident Report, dated 2/29/2024, reflected Resident #1 reported to the facility during the months of September and October 2023, COTA D had gaslight me and groomed me for a relationship and she realized he had been taking advantage of her. The report reflected COTA D had intercourse with Resident #1 in the resident's room. Record review of the Police Report Case Identification Number 24-00293, dated 2/29/2024, reflected the police were informed by the facility of COTA D's inappropriate sexual behavior with residents. Record review of COTA D's personnel file revealed the COTA was hired on 5/22/2024, suspended on 2/21/2024, and his employment was terminated on 2/28/2024. The personnel file revealed COTA D was given a verbal warning on 10/12/2024 regarding following professional boundaries because of a rumor that he and Resident #1 were planning to move in together after the resident was discharged . On 1/8/2024 COTA D was given a written warning because he was not following the residents plan of care, Medicare guidelines for documentation and he was working overtime without approval. A disciplinary action form initiated 2/27/2024 and signed on 2/28/2024 revealed COTA D was terminated due to inappropriate relations and unprofessional conduct with facility a facility resident and former resident. During an interview on 5/22/2024 at 10:27 a.m. with the PNP she stated the SW referred Resident #1 when information came out about the resident's intimate relationship with COTA D. The PNP stated the resident was vulnerable when COTA D began taking interest in the resident. The PNP reported as their relationship progressed, COTA D told Resident #1 he could provide her a stable relationship and a home for them to live together. The PNP stated Resident #1 expressed increased depression, so she increased the resident's antidepressant dosage. The PNP stated Resident #1 scored high on her anxiety assessment, but the resident was already on an anti-anxiety medication, and the resident did not appear anxious during their meeting. The PNP reported she could not say for sure if the incident made the resident mentally upset, and because the resident was already depressed before the incident, the PNP stated it was difficult to gauge what emotional impact the incident had on the resident. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1 she stated she began receiving occupational therapy with COTA D and continued having a relationship until her surgery in November 2023. Resident #1 stated the COTA started grooming me from the beginning, telling the resident she was a beautiful woman and how great she would look when she lost weight (Resident #1 was scheduled for Lap band surgery in November 2023). Resident #1 reported when she first began working with COTA D, she was engaged to another male living in the community and the COTA was aware of their relationship. Resident #1 stated when she began having problems with her relationship with her fiancee, she would confide in COTA D, and he was supportive. Resident #1 stated she was in a vulnerable state when their romantic relationship began in September 2023. She reported COTA D was her Knight in Shining [NAME], telling her he bought a house for them to move in together and he would paint pictures of a fabulous life and how he would take care of me. Resident #1 reported at that time the COTA was taking her out to eat in the evenings at a restaurant nearby and he would take her to lunch to meet her family, who were visiting from out of town. Resident #1 stated at first COTA D did not stay when he took her to see her family, but a short time later he began joining them for lunch. Resident #1 also reported it was in September 2023 that they had intercourse in the resident's room. Resident #1 reported it was late in the evening, and COTA D checked that all the department heads left for the day. Resident #1 reported they only had intercourse one time. Resident #1 stated in November 2023, their relationship ended, however, the COTA would still kiss her and rubbed her buttocks during her cryotherapy (or cold therapy, where low temperatures are used as part of the therapy treatment to relieve muscle pain or swelling after surgery). Resident #1 reported she found out later that COTA D told her fiancee he never had any intention of the resident moving in with him, and he only said this to motivate her in therapy. The resident reported staff would see them together, but COTA D never did anything inappropriate in front of them. Resident #1 reported the Administrator had asked her in September 2023 if she and the COTA had a serious relationship and she told the Administrator they were just friends. She also reported the Administrator asked her again about a relationship between her and COTA D in November 2023, and she told him no. The resident reported by that time it was over and she was telling the truth. Resident #1 stated only one resident asked her if she was having a relationship with COTA D. Resident #1 reported COTA D was still calling her after he no longer worked for the facility, and she told him to stop calling her and he blocked his phone number on her cell phone. During an interview on 5/22/2024 at 1:56 p.m. with CNA B, she stated she saw COTA D take Resident #1 to the nearby restaurant and the COTA stated they were going out to eat with her family and it was part of her therapy. The CNA stated she never saw COTA D take any other resident outside of the facility. CNA B stated she thought it was odd the COTA was taking the resident out to eat but she never told anyone. CNA B could not provide a reason why she did not tell anyone. During an observation and interview on 5/22/2024 at 2:55 p.m. with HA C she stated after the first State Surveyor went to the facility to investigate the incident, the CNA the resident was not herself and appeared more depressed now that she began telling others about her past relationship with COTA D. During a telephone interview on 5/24/2024 at 3:00 p.m. with Resident #1's FEC she reported she first met COTA D in September 2023 at the facility. The FEC stated the COTA was cordial but felt conversations with the COTA were forced conversations. Resident #1's FEC stated when they ate with Resident #1 and COTA D, the COTA stated he was looking for wife-material, referring to the resident. The FEC stated at the time Resident #1 had another boyfriend who lived in the community but stated COTA D promised to move her in with him in his new home. The FEC stated they had lunch with the COTA at least 4 times. The FEC stated she recalled another incident when she saw COTA D working with another resident, the COTA helped the resident up from the chair holding her buttock instead of under the resident's arms. Resident #1's FEC stated she could not recall when this occurred, and she did not know who the resident was. The FEC did not state if she told anyone about what she witnessed. During an interview on 5/24/2024 at 6:15 p.m. with CNA E and CNA F both reported they saw COTA D take Resident #1 out to eat several times on weekends. They reported they told RN G the COTA was taking the resident out to dinner. During an interview on 5/24/2024 at 6:18 p.m. with RN G she reported she saw COTA D dressed in a suit, Resident #1 had make-up on and was wearing a dress, and the COTA took the resident out to eat. RN G stated she saw COTA take the resident out two times and she never saw the COTA enter the resident's room. RN G stated she spoke to Resident #1, and the resident was excited, and giddy that COTA D was paying attention to her. The RN stated the resident would sign herself out. RN G asked Resident #1 if there was more than a friendship between the therapist and resident, and the resident stated they were just friends. RN G stated she never told anyone because she thought administration knew he was taking her out to eat. During an interview on 5/22/2024 at 1:39 p.m. with the SW, she stated she was not aware of any inappropriate behavior by COTA D until after everything came out. 2. Record review of Resident #2's face sheet dated 5/24/2024 reflected the resident was a [AGE] year-old female who was initially admitted on [DATE], and a readmitted [DATE]. Resident #2 had diagnoses which included cerebral infarction (a brain injury caused by disruption of blood flow to the brain), hemiplegia (severe or complete paralysis on one side of the body) and hemiparesis (one-sided muscle weakness because of disruptions in the brain, spinal cord, or the nerves that connect the affected muscles) following cerebral infarction affecting right dominant side, major depressive disorder major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and central pain syndrome (a rare neurological condition that causes chronic pain due to damage to the central nervous system). Record review of Resident #2's annual MDS assessment, dated 5/2/2024, reflected the resident had a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #2's care plan reflected the resident was receiving pain medication therapy which included Gabapentin and Baclofen. Record review of Resident #2's Quarterly MDS assessment, dated 2/7/2024, reflected the resident had an occupational therapy start date of 2/1/2024. During an interview on 5/22/2024 at 11:36 a.m. with Resident #1, she stated Resident #2 told her COTA D would take Resident #2's pants off during occupational therapy. During a telephone interview on 5/22/2024 at 2:20 p.m. with CNA A, she reported one day she noticed Resident #2's door was shut, and she thought that was odd because the resident always left her door open. CNA A stated she knocked, and then opened the door and saw COTA D sitting in the resident's room with his hand on the resident's leg and they were watching television. The CNA explained she saw the COTA was sitting in a chair next to the bed and the resident was in bed. CNA A stated Resident #2 was not wearing any pants and only her brief and a shirt. The CNA stated she could only see COTA D's one hand on her knee and did not know where his other hand was. CNA A stated the COTA and resident did not say anything, and she apologized and walked out. CNA A stated she thought it was a few months ago. The CNA stated she spoke to Resident #2 later and asked her if she felt uncomfortable with COTA D and she said no. The CNA stated she did not tell anyone until recently when questioned about COTA D by administrative staff. During an interview on 5/22/2024 at 1:56 p.m. with CNA B she stated Resident #2 told her whenever she and COTA D had a therapy session, he would take off her pants. Resident #2 told her not to tell anyone. CNA B stated when COTA D started doing therapy sessions with Resident #2 in the therapy room, the resident got made at the CNA, thinking she had told someone. The CNA stated she did not tell anyone about COTA D removing Resident #2's pants because the resident asked her not to. During an interview on 5/24/2024 at 11:14 a.m. with Resident #2 she reported she worked with COTA D a couple of days. The resident reported during their therapy sessions he was working with her legs. Resident #2 stated COTA D took off her pants when he was working with her. The resident stated she was wearing a brief. Resident #2 reported she did not ask the COTA why he removed her pants. Resident #2 stated the COTA would touch and rub her legs, but he never explained anything while he worked with her. Resident #2 stated, it made her feel terrible when COTA D took off her pants. Resident #2 stated on one occasion a CNA walked in when she was working with COTA D and her pants were off. The resident stated the CNA did not say anything. Resident #2 stated the COTA had not touched her anywhere else but her legs when he worked with her. 3. Record review of Resident #3's face sheet, dated 5/24/2024, reflected the resident was a [AGE] year-old female with an original admitted [DATE], a readmitted [DATE], and a discharge date of [DATE]. Resident #3's had diagnoses which included hepatorenal syndrome (a life-threatening condition that occurs when the kidneys of someone with advanced liver disease begin to fail), hypertension (high blood pressure), (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (frequent feelings of fear and worry that is intense and excessive), and chronic pain. Record review of Resident #3's 5-day MDS assessment, dated 1/17/2024, reflected the resident began occupational therapy on 1/24/2024 and received therapy 4 days a week. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator he reported around mid-February, he learned a previous resident, Resident #3, was at the hospital, was being released soon, and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not the facility. The Administrator reported when Resident #3 stayed at the facility before she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident had confided in her that she did not want to return to the facility because of COTA D and he had visited her home a couple of times after she discharged , and he was handsy (touch other people in a way that is inappropriate or unwanted). The Administrator reported she assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D gave her thong underwear one of the times he visited her home. During an interview on 5/24/2024 at 4:10 p.m. with the Marketing Director she reported she was a family friend of Resident #3, and the resident told her about COTA D being inappropriate with her on her previous visit. The Marketing Director stated Resident #3 initially enjoyed the attention COTA D was giving her but when the resident felt the COTA wanted more than a friendship, she felt uncomfortable. During an interview on 5/27/2024 at 10:01 a.m. with Resident #3, she reported while she was at the facility on her previous visit, she received occupational therapy by COTA D. Resident #3 stated when COTA D was massaging her back, he began fondling her private area and COTA D told Resident #3, I am gonna tap (slang for sexual intercourse) that one day. The resident stated she did not report it to the facility because she was afraid to. Resident #3 stated COTA D was tall at 6'4'' and a big man, and she was afraid of him so when he asked for her telephone number when she was ready to discharge, she gave it to him. Resident #3 reported when she was back in the community living at her apartment COTA D called her and said he was coming over to see that her home was handicap accessible and she did not know what to say. Resident #3 stated she had gone out to eat with the COTA at that time because he insisted, she go. That was when he came into her apartment the first time, stating he needed to check that her apartment was handicap accessible. The resident stated COTA D came over to her apartment, but the resident stated she did not know how he got her address. Resident #3 stated the COTA came over to her apartment a second time and brought her a gift, thong underwear. The resident stated COTA D wanted her to wear the underwear in front of him and initially she said no but she felt intimidated because she was by herself, so she wore the underwear in front of him and then changed and told the COTA to leave. Resident #3 stated COTA D showed up a third time, wanted the resident to sit on his lap but she refused so he left. Resident #3 stated COTA D never showed up again. Resident #3 stated she did not know what to do when he wanted to come over. 4. Record review of Resident #4's face sheet dated 5/24/2024 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses that included dementia without behavioral disturbance, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (high blood pressure), and pain. Record review of Resident #4's Quarterly MDS assessment, dated 2/19/2024, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact and no mood or behavioral concerns. Record review of Resident #4's May 2024 Consolidated Physician Orders reflected the resident was discharged from occupational therapy services on 1/26/2024. Review of Record review of Resident #4's care plan initiated 8/11/2017 reflected the resident received pain medication which included Tramadol and gabapentin. During an interview on 5/23/2024 at 11:03 p.m., Resident #4 stated she received therapy at the facility, and she did not especially want it. Resident #4 stated she had a male therapist who made her feel uncomfortable. She provided COTA D's first name and gave a brief description. Resident #4 stated during a therapy session, her back was hurting and COTA D pulled her pants down a bit to put some Bio-freeze on her buttock, and she thought this was odd. The resident reported this only happened once. Resident #4 stated she told an unidentified staff member about the incident and the staff member told her to wait and see if he does it again. Resident #4 stated she did not recall who the staff member was. The resident stated the incident happened over 6 months ago in the therapy room while she was lying on the table. She did not report if anyone else was present. During an interview on 5/23/2024 at 12:43 p.m., the Administrator stated Resident #4 never said anything when they interviewed residents for concerns related to abuse and neglect. 5. Record review of Resident #5's face sheet dated 5/24/2024 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should), shortness of breath (feeling you cannot get enough air into your lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus without complications (when the pancreas does not make enough insulin), and unspecified pain. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #5's May 2024 Concentrated Physician Orders reflected the resident had an order for Lidocaine patch and gabapentin for pain and she was discharged from occupational therapy on 4/2/2024. Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected the resident received occupational therapy with a start date of 11/10/2023 and an end date on 1/5/2024. During an observation and interview on 5/24/2024 at 7:35 p.m. with Resident #5 revealed she received occupational therapy from COTA D. the Resident #5 stated while COTA D was rubbing her back, he began rubbing her buttock and intergluteal cleft (the posterior deep midline groove in the gluteal region that separates the buttocks). Resident #5 showed the region on her body where the therapist had rubbed her. The resident's voice got louder as she talked about it. Resident #5 stated it only happened one time. The resident stated she told the Administrator about it. During an interview on 5/24/2024 at 8:02 p.m. with the Administrator he stated they interviewed Resident #5 regarding abuse and neglect and the resident never reported COTA D touching her inappropriately. The Administrator went on to say he did not recall Resident #5 telling him about the incident and stated he would have remembered something like it. During an interview on 5/22/2024 at 12:30 p.m. with the DOR she stated she began working at the facility PRN in June 2023, and became the DOR in July 2023. The DOR reported COTA D was already working at the facility when she started. The DOR stated she and several members of management had verbally in-serviced the COTA about following each of the residents Plan of Care that was established by the OT when the resident was evaluated. The DOR reported COTA D was reporting additional hours and provided other treatments, including taking Resident #1 out for lunch to meet with her family several times, not prescribed on the Plan of Care, which was outside his scope of practice. The DOR stated COTA D would follow the Plan of Care for a while but then would go back to providing treatment outside the COTA's scope of practice. The DOR reported Resident #1 spoke to her about going on a weekend pass to see COTA D's new house but knew the Administrator had already spoken to the COTA regarding rumors the COTA and Resident #1 had planned to live together after she discharged . The DOR stated Resident #1 later reported they were having a consensual relationship, but he was gaslighting (a form of emotional abuse that causes the victim to question their own feelings) the resident. The DOR reported sometime in August (she could not recall the date), during a weekend, she witnessed COTA D was all dressed up and pushing Resident #1 in her wheelchair out of the facility. The DOR reported she told the Administrator, and the DOR was off the clock at the time. The DOR stated COTA D was fired on 3/4/2024. During a telephone interview on 5/22/2024 at 3:57 a.m. with COTA D, he reported he had been a COTA for [AGE] years and began working at the facility on May 22, 2023. COTA D stated he gave statements to the licensing board and the facility should have a copy. The COTA stated he would not say any names of the residents he worked with and anything about the incidents. He stated when he was working at the facility, he would work 8, 9, or 10 hours a day. COTA D stated some residents were bedbound so therapy would begin in their room and as they progressed, they went to the gym. The COTA reported there was a restaurant about two blocks away from the facility and he would accompany the residents with their families for integration back into society and it was part of the residents' therapy treatment. COTA D stated no resident had ever been to his home. The COTA stated as part of COTA treatment they did home evaluations, home assessments, and home health. COTA D stated he did several home evaluations and house assessments during his career. The COTA reported they did not have relationships with their residents. COTA D stated sometimes residents were drawn by skilled, knowledgeable healthcare workers. COTA D stated he recalled everyone gave a resident a gift and his gift were a pair of shorts. The COTA stated the resident was female and she would wear shorts to therapy. COTA D stated that I do not have any relationship with residents. When the COTA was asked if he was working again, he stated, You do not need to worry about his personal business. During a telephone interview on 5/24/2024 at 2:54 p.m. with the Medical Director she reported she was made aware of the IJ. The Medical Director reported they also had a QAPI after the IJ was called. The Medical Director stated no residents were identified when she spoke to the Administrator and during QAPI. The Medical Director reported Resident #2 was one of her residents she saw at the facility and was not aware of the incident. The Medical Director noted she did have another physician that took calls for her and assisted with the residents at the facility, and he may have been informed about the incident with Resident #2. The Medical Director stated she would follow up with Resident #2 herself to see that she was doing okay. During an interview on 5/22/2024 at 4:46 p.m. with the Administrator, he reported on 10/12/2023 he spoke to COTA D about rumors the COTA and Resident #1 were going to move in together when she was discharged . The Administrator reported COTA D denied the allegation and stated they were just friends. The Administrator reported he discussed professional boundaries with the COTA and reviewed the Code of Ethics between a therapist and resident. The Administrator also had COTA D sign a written warning letter to confirm he was instructed and understood ethical boundaries. The Administrator stated he then went to talk to Resident #1 about the rumor and at that time Resident #1 was asking about going out on pass to see COTA D's new home. The resident reported to the Administrator she and her parents were going to see COTA D's house he recently purchased. The Administrator stated he questioned Resident #1 about the rumors she was planning to move in with COTA D, and the resident denied the relationship and stated they were just friends. The Administrator reported Resident #1 never went out on pass to see the COTA's house. The Administrator stated at the time he believed COTA D was telling the truth, He was so convincing by the way he responded, and other residents reported how much they liked him. The Administrator stated the COTA was also disciplined for taking extra-long time with each treatment he was providing, running more labor hours per resident. The Administrator reported it eventually got better after several talks with COTA D. The Administrator reported he discovered Resident #1 and COTA D had a romantic relationship on February 29, 2024. The Administrator reported initially around mid-February, he learned a previous resident, Resident #3, was at the hospital and being released soon and told the facility Admissions Coordinator, who also marketed for their sister facility in town, that she would go to any other facility, just not to their facility. The Administrator stated when Resident #3 stayed at the facility before, she told them she was pleased with their care. The Admission Coordinator, who was also a family friend of Resident #3, reported the resident confided in her that she did not want to return to the facility because of COTA D and that he had visited her home a couple of times after she discharged , and he was handsy (touching other people in a way that is inappropriate or unwanted). The Administrator reported he assured Resident #3 that COTA D would not be providing her therapy and the Administrator then told the COTA he was suspended and sent him home. The Administrator stated after Resident #3 admitted back to the facility, she also reported COTA D had given her thong underwear one of the times he visited her home. The Administrator reported they began interviewing all residents on abuse and neglect, asking the residents if they ever had any issues with staff, and that was when Resident #1 reported she had a sexual relationship with COTA D. The Administrator also spoke to staff and learned that CNA A walked into Resident #2's room and the COTA was in the room and the resident was not wearing pants. The Administrator also reported he learned Resident #2 told CNA B that COTA D took her pants off during therapy. The Administrator reported no other residents reported an incident with COTA D. The Administrator stated he made a referral to the OT/COTA licensing board, but he did not receive copies of the COTA's statement to the board) Record review of the facility's policy titled, Abuse/Neglect, revised 10/14/2022, reflected, Resident's should not be subject to abuse by anyone, including, but not limited to facility staff. 4. Sexual Abuse-non-consensual sexual contact of any type with a resident. C. Prevention, 3. All reports of abuse or suspicion of abuse/neglect or potential criminal behavior will be investigated as per facility policy and 5. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. D. Identification, Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and /or Adult Protective Services. E. Investigation, The Administrator or Risk Management Department will be responsible for investigation and reporting cases to Health and Human Services Commission. F. Protection, The facility will take necessary measures to protect residents .during and following an abuse, neglect, and exploitation, misappropriation of residents or misappropriation of resident property investigation. Record review of the Occupational Therapy Code of Ethics and Ethics Standards (2010) provided by the facility, under the heading, Nonmaleficence, reflected Occupational therapy personnel shall: C. Avoid relationships that exploit the recipient of services . physically, emotionally, psychologically, financially, socially, or in any other manner that conflicts or interferes with professional judgement and objectivity, .D. Avoid engaging in any sexual re[TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure general cleanliness was maintained in the kitchen. 3. The facility failed to ensure hairnets were worn. 4. The facility failed to ensure staff did not use hands when serving food. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on [DATE] @ 9:05 AM revealed the following: 1. (3) bags of tater tots, no label or date, not in the original box. 2. (1) bag of frozen dumplings, no label or date, not in the original box. Observation of the kitchen food prep area on [DATE] at 9:10 am revealed the following: 1. 1 opened bottle of coca cola, money, and a lady's purse on the kitchen prep area counter. 2. Several bottles of decorating sugar with a best by date of ,d+[DATE] 3. A container of baking powder with a use by date of [DATE] 4. A bottle of creole seasoning with a use by date of [DATE] 5. A bottle of celery salt with a best by date of ,d+[DATE]. 6. A bottle of nutmeg with a best by date of [DATE] 7. A metal container of flour was observed with a large flour bag on top of the loose flour inside the bin. The bin was grimy and sticky to the touch. The lid was not properly secured on the bin. 8. A metal container of rice was grimy and sticky to the touch. The lid was not properly secured on the bin. 9. Bags of Pasta, Stuffing and French-fried onions were stored inside pots and pans in the kitchen prep area. Observation of the cooler on [DATE] at 9:14 am, revealed a package of cheese, no label or date, not in original box. In an observation and interview of the lunch service on [DATE] at 12:00 pm, [NAME] G was observed touching kitchen surfaces with gloved hands in the kitchen. [NAME] G touched the steam table, took foil off pans of food, and picked up serving utensils and plates during the noon meal service. [NAME] G did not wash her hands or change her gloves. During that time, [NAME] G began plating the food then picked up a biscuit with her gloved hand and placed the roll on the plate. This was done 2 times before surveyor intervention. The DM was also present and observed [NAME] G pick up a biscuit with her gloved hand. [NAME] G did not wash hands or change gloves between tasks. [NAME] G stated she just forgot and was supposed to use tongs when touching bread. [NAME] G stated not changing gloves and using tongs could cause cross contamination and illness for the residents. The DM stated she oversaw training, and she talked to the staff all the time about hand washing and the use of tongs. The DM stated [NAME] G knows better than to use her hands and was nervous. The DM stated this could cause cross contamination for the residents. Observation on [DATE] at 1:25 pm revealed [NAME] H was in the kitchen prep area with no hairnet. He stated, I rub my head and it just comes off. Observation of the kitchen food prep area on ,d+[DATE] /24 at 1:30 pm revealed metal containers of flour, and rice were sticky and grimy to the touch. The container lids had food crumbs on the top and were sticky to the touch. The lids were not secured. The flour bin had bags of additional flour sitting on top of the loose flour in the bin. In an observation and an interview on [DATE] at 2:47 pm, [NAME] H was observed in the kitchen dishwashing area with no hairnet. [NAME] H stated he did not realize he did not have it on. [NAME] H stated he had just come back into the kitchen and had forgotten. [NAME] H stated the consequences of not wearing a hairnet was hair in the kitchen. In an interview and a walk through with the DM on [DATE] at 2:15 pm, the DM stated of the issues with the food grime and crumbs on the containers of the rice and flour containers and the expired spices in the kitchen that she is sorry they had missed it and she will get it cleaned. The DM stated she expects all staff to be cleaning daily. The DM stated she had been out of the facility, and it was just missed. The DM stated she trained the staff on cleaning practices and the labeling and dating of foods. The DM stated she expects all staff to label and date all food items after they use the package. The DM stated the consequences of not labeling and dating foods could cause residents to have food borne illnesses. The DM stated the consequences of not storing food properly would possibly make the residents sick if consumed. She further stated residents could get sick from the food not being covered or refrigerated after being opened. The DM stated she was aware staff were to always wear hairnets in the kitchen and had been telling [NAME] H to put one on all day. The DM stated a consequence of not having hairnets on would be hair in the food and on kitchen surfaces. The DM stated [NAME] G was just nervous when she touched the bread without tongs. The DM stated [NAME] G knew she was supposed to use tongs. Record Review of the policy dated 2012, titled Sanitation and Food Handling documented: Hair nets are to be always worn. Handle all utensils and dishes so the food or customer contact surfaces are not touched. Do not handle food with bare hands. Use the proper utensils or wear disposable gloves. Remember to change the gloves after touching anything that should not contact food, including hair, clothing, doorknobs, etc. All unused food must be securely covered. All items are to be labeled and dated as to their contents. Store items in their original container Record Review of the policy dated 2012, titled Work Conduct documented: All personal belongings (cigarette packages, sweaters, papers, books, cell phones and purses) must be kept out of the food preparation area. There is to be no eating while on duty, except in the employee dining area during scheduled breaks. Record Review of the policy dated 2012, titled Infection Control documented: Hair is to be covered with an effective hair restraint. Careful handwashing will be done between handling of cooked and uncooked foods, between handling of dirty dishes, boxes, or equipment and handling clean food or utensils. All kitchen ware and food contact used in the preparation and /or serving of food are cleaned and sanitized before use and after each meal preparation. There shall be no bare hand contact. All kitchen ware and food contact surfaces will be cleaned and sanitized after each use. Record Review of the policy dated 2012, titled Food Safety documented: Food is to be tightly wrapped or sealed in covered containers. Opened food shall be covered, labeled, and dated. Never store scoops ladle or other food contact equipment directly in the food container. Do not keep food past the labeled expiration date. Gloves must be worn for preparation and service of foods that do not require further cooking. Record Review of the policy dated 2012, titled Dry Storage and Supplies documented: Dry bulk foods will be stored in seamless metal or plastic containers with tight lids or covers which are easily sanitized. Scoops should not be left in bins. Containers are cleaned regularly.

Based on interview and record review, the facility failed to ensure comprehensive care plans were developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment which included both the comprehensive and quarterly review assessments for 7 of 18 residents (Residents #1, #3, #23, #31, #33, #35 and #38) reviewed for comprehensive care plans. The facility failed to update the comprehensive person-centered care plans to address the needs of Residents #1, #3, #23, #31, #33, #35 and #38 within 7 days after MDS assessments were completed. This deficient practice could place residents at risk of delayed treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #1's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but not limited to, Cerebral Palsy (neurological disorder that affect movement and muscle ton due to brain injury or malformation before, during, or after birth), psychotic disorder with delusions (mental health condition in which a person can't tell what's real from what's imagined), atherosclerotic heart disease of native coronary artery without angina pectoris (narrowed arteries close to the heart which can cause chest pain) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident #1's MDS assessments, undated, reflected three MDS assessments with the following completed dates: 7/7/23 (Annual), 10/19/23 (Quarterly), and 1/7/24 (Quarterly). Record review of Resident #1's, undated, care plans reflected three care plans completed with the following dates: 6/15/23 (23 days prior to completion of annual MDS assessment), 9/12/23 (25 days prior to completion of quarterly MDS assessment, and 12/12/23 (26 days prior to completion of quarterly MDS assessment). 2. Record review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included, but not limited to, Fragile X Chromosome (genetic disorder characterized by mild-to-moderate intellectual disability), borderline personality disorder (mental health disorder that impacts the way you think and feel about yourself and others, causing problems functioning in everyday life), unspecified intellectual disabilities (limitations in mental abilities that affect intelligence, learning, and everyday life skills), and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Record review of Resident #3's MDS assessments reflected the following dates the assessments were completed: 12/21/23 (Quarterly), 12/4/23 (Quarterly) and 9/10/23 (Quarterly). Record review of Resident #3's care plans reflected three care plans were completed with the following dates: 11/2/23 (49 days prior to completion of quarterly MDS assessment), 8/8/23 (33 days prior to MDS assessment completed 9/10/23) and 5/9/23. There were no additional care plans to correspond with the three dates provided for the MDS assessments. 3. Record review of Resident #23's face sheet, dated 1/29/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #23 had diagnoses which included, but were not limited to, unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes (problem in the way the body regulates sugar), anxiety disorder (consistent fear and worry), and atherosclerotic heart disease of native coronary artery without angina pectoris (narrowed arteries close to the heart which can cause chest pain). Record review of Resident #23's MDS assessments reflected the following dates of completed assessments: 1/4/23 (Quarterly), 10/18/23 (Quarterly), and 7/17/23 (Quarterly). Record review of Resident #23's completed comprehensive care plans reflected the following dates: 1/3/24 (1 day prior to completion of MDS assessment), 11/8/23 (21 days after completion of MDS assessment), and 7/26/23 (9 days after completion of MDS assessment). 4. Record review of Resident #31's face sheet, dated 1/30/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included, but were not limited to, unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life), anxiety disorder (consistent fear and worry), insomnia (trouble falling or staying asleep), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of MDS assessments completed for Resident #31 reflected the following dates each assessment was completed: 10/4/23 (Quarterly), and 9/15/23 (Annual). Record review of completed comprehensive care plans for Resident #31 reflected two completed care plans dated 7/26/23 and 4/26/23. 5. Record review of Resident #33's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a readmitted [DATE]. Resident #33 had diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and diminished strength of one side of the body following a stroke), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety disorder (consistent fear and worry), and central pain syndrome (rare disorder that makes the brain feel pain without any injury to the body). Record review of Resident #33's MDS assessments reflected the following completion dates: 11/19/23 (Quarterly), 8/29/23 (Quarterly), and 6/5/23 (Annual). Record review of Resident #33's care plans reflected the following completed dates: 1/3/24 (45 days after comprehensive assessment completed 11/19/23), 9/7/23 (9 days after MDS assessment completed on 8/29/23), and 4/26/23 (40 days prior to MDS assessment completed on 6/5/23). 6. Record review of Resident #35's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a readmit on 11/18/23. Resident #35 had diagnoses which included, but were not limited to, heart failure, type 2 diabetes (problem in the way the body regulates sugar), obesity, major depressive disorder (persistent feeling of sadness and loss of interest), and anxiety disorder (consistent fear and worry). Record review of Resident #35's MDS assessments reflected the following completion dates: 1/4/24 (Annual), 11/13/23 (Quarterly), and 8/16/23 (Quarterly). Record review of Resident #35's care plans reflected the following completed dates: 1/17/24 (13 days after the completed MDS assessment dated [DATE]). No care plan was completed for MDS assessment dated [DATE]. 7. Record review of Resident #38's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included, but were not limited to, dementia (group of symptoms that affects memory, thinking and interferes with daily life), hypertension (high blood pressure), syncope and collapse (sudden loss of consciousness and muscle strength), and edema (swelling due to excess fluid). Record review of Resident #38's MDS assessments reflected an assessment was completed on 1/23/24. Record review of Resident #38's care plan reflected a completed date of 1/3/24 (20 days prior to the completion of the MDS assessment on 1/23/24). An interview on 01/31/24 at 10:02 AM, MDS N stated care plans should be completed 7 days after the MDS assessment is completed. MDS N stated the DON started the care plan. MDS N stated a negative outcome was staff didn't have an accurate care plan and the care plans were not updated. An interview on 01/31/24 at 10:18 AM, the DON stated he was responsible for care plans. The DON stated the SW did a care plan when the resident was to return home but about 95% of it was the DON. The DON stated care plans were done quarterly but care plans were all updated in real time and there were many areas the care areas were pulled from. The DON stated the EMR was not perfect with it. The DON stated the care plan were updated with anything specific to medication, specific to admission (readmission). If the resident was out for several months, the DON stated he reactivated them but didn't change the date. MDS N oversaw uploading the care plans. The DON stated there was no negative outcome because care plans were comprehensive; there was nothing in the MDS that was not already in the care plan. The DON stated he was unaware where care areas were pulled from. Record review of the facility policy titled Care Plans, revised 10/4/22, reflected on line 3, The comprehensive care plan must be developed within seven days after completion of the comprehensive assessment. Line 4. The comprehensive care plan will be reviewed regularly, as per guideline, and/or with significant change and revised by a team of qualified person after each assessment. Record review of the facility policy titled IDT Inservice- Care Plans, updated 2/7/23, reflected on the third bullet point- The comprehensive care plan needs to be completed no later than day 21 or the date signed on the care plan decisions on the MDS. The Fourth bullet point read- There needs to be a care plan review with each completed MDS (Quarterly, Annual, Sig . Change). Under heading Care Plan Meeting, it read: - Care plan will be scheduled about 2 weeks after the ARD . - MDS Coordinator will complete the MDS and do the care plan review before the care plan meeting. Record review of the Resident Assessment Instrument 3.0, dated October 2023, Chapter two page 17-18 reflected a table showing when items should be completed with a comprehensive assessment. Under heading Care Plan Completion Date- Admission (Comprehensive), Annual (Comprehensive), Significant Change in Status (SCSA) (Comprehensive), and Significant Correction to Prior Comprehensive (SCPA) (Comprehensive), all are noted to be timed at CAA(s) Completion date plus 7 calendar days.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 8 (Resident #3, #9, #16, #21, #22, #23, #33, and #49) of 18 residents reviewed for advanced directives. The facility failed to ensure Residents #3, #16, #21, #22, #23, and #33 DNR's were not missing information in the Physician Statement Section. The facility failed to ensure Resident #9's DNR was not missing information in the Witness Section. The facility failed to ensure Resident #49's DNR was not missing information in the Physicians Statement Section and a different DNR in her printed record that was missing information in the Physicians Statement Section. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #3 Record review of the face sheet dated [DATE] in the clinical record for Resident #3 revealed a [AGE] year-old male resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include epilepsy (a disorder that causes abnormal brain function, seizures), major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), unspecified intellectual disabilities (a developmental disorder characterized by less than averaged intelligence and significant limitations in adaptive behavior), and schizophrenia, (a serious mental health disease that causes altered perception of reality). Under the section Advanced Directives Resident #3 was listed as a DNR. Record review of the clinical record for Resident #3 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 2 indicating he was severely cognitively impaired, and he required supervision with most of his activities. Record review of the clinical record for Resident #3 revealed a care plan with an admitted [DATE] with the following: Resident #3 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #3 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #3 revealed a DNR dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no license number for the physician's signature. Resident #9 Record review of the face sheet dated [DATE] in the clinical record for Resident #9 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include dementia (cognitive loss), muscle wasting (breakdown of muscles), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), atrial fibrillation (abnormal heartbeat), major depression (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), cardia arrythmia (a condition in which the heart beats with an irregular or abnormal rhythm). Under the section Advanced Directives Resident #9 was listed as a DNR. Record review of the clinical record for Resident #9 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 1 indicating she was severely cognitively impaired, and she was dependent on others to complete her activities of daily living. Record review of the clinical record for Resident #9 revealed a care plan with an admitted [DATE] with the following: Resident #9 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #9 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #9 revealed a DNR dated [DATE] (signed by the resident) with the following: Section-Witnesses-there was no printed signature for either witness. Resident #16 Record review of the face sheet dated [DATE] in the clinical record for Resident #16 revealed a [AGE] year-old male resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), acute kidney failure (disease of the kidneys leading to kidney failure), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Under the section Advanced Directives Resident #16 was listed as a DNR. Record review of the clinical record for Resident #16 revealed the last MDS completed was a significant change of condition status dated [DATE] with a BIMS of 6 indicating he was severely cognitively impaired, and he required supervision with most of his activities. Record review of the clinical record for Resident #16 revealed a care plan with an admitted [DATE] with the following: Resident #16 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #16 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #16 revealed a DNR dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no printed signature for the physician. Resident #21 Record review of the face sheet dated [DATE] in the clinical record for Resident #21 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), hemiplegia (loss of use of the left side of the body), hypertension (high blood pressure), pain, major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Under the section Advanced Directives Resident #21 was listed as a DNR. Record review of the clinical record for Resident #21 revealed the last MDS completed was a significant change of condition dated [DATE] with a BIMS of 15 indicating she was cognitively intact, and she was dependent on others to complete her activities of daily living. Record review of the clinical record for Resident #21 revealed a care plan with an admitted [DATE] with the following: Resident #21 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #21 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #21 revealed a DNR dated [DATE] (signed by the resident) with the following: Section-Physician Statement-there was no printed signature for the physician. Resident #22 Record review of the face sheet dated [DATE] in the clinical record for Resident #22 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), alcohol use with alcohol-induced persisting dementia, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypertension(a condition in which the foresee of the blood against the artery walls is too high), pulmonary embolism(clot blocking blood flow to lungs. alcoholic cirrhosis of the liver (an advanced stage of alcoholic liver disease that cause your liver to become stiff, swollen, and barely able to do its job), chronic hepatitis (inflammation of the liver), alcohol-induced pancreatitis (an advanced stage of alcoholic disease that cause your pancreas to become stiff, swollen, and barely able to do its job). Under the section Advanced Directives Resident #22 was listed as a DNR. Record review of the clinical record for Resident #22 revealed the last MDS completed was a significant change of condition status dated [DATE] with a BIMS of 5 indicating he was severely cognitively impaired, and he required partial to moderate assistance with most of his activities. Record review of the clinical record for Resident #22 revealed a care plan with an admitted [DATE] with the following: Resident #22 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #22 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #22 revealed a DNR dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no license number provided for the physician. Resident #23 Record review of the face sheet dated [DATE] in the clinical record for Resident #23 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include myocardial infarction (heart attack), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), coronary atherosclerotic heart disease (damage or disease in the hearts major blood vessels), unspecified psychosis(severe mental disorders that cause abnormal thinking and perceptions), dementia (a group of thinking and social symptoms that interferes with daily functioning), Under the section Advanced Directives Resident #23 was listed as a DNR. Record review of the clinical record for Resident #23 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 3 indicating she was severely cognitively impaired, and she requires moderate to substantial assistance with all her activities of daily living. Record review of the clinical record for Resident #23 revealed a care plan with an admitted [DATE] with the following: Resident #23 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #23 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #23 revealed a DNR dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no license number provided for the physician. Resident #33 Record review of the face sheet dated [DATE] in the clinical record for Resident #33 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), paranoid schizophrenia(a disease that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), pain, hypertension (a condition in which the foresee of the blood against the artery walls is too high), hemiplegia (partial paralysis). Under the section Advanced Directives Resident #33 was listed as a DNR. Record review of the clinical record for Resident #33 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 10 indicating she was moderately cognitively impaired, and she was dependent on staff for assistance with all her activities of daily living. Record review of the clinical record for Resident #33 revealed a care plan with an admitted [DATE] with the following: Resident #33 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #33 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #33 revealed a DNR dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no printed signature for the physician. Resident #49 Record review of the face sheet dated [DATE] in the clinical record for Resident #49 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include pain, dysphagia (difficulty swallowing), dementia(a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), diabetes(a chronic condition that affects the way the body processes blood sugar (glucose), hypertension (a condition in which the foresee of the blood against the artery walls is too high). Under the section Advanced Directives Resident #49 was listed as a DNR. Record review of the clinical record for Resident #49 revealed the last MDS completed was an admitted d [DATE] with a BIMS of 4 indicating she was severely cognitively impaired, and she required moderate to substantial assistance with all her activities of daily living. Record review of the clinical record for Resident #49 revealed a care plan with an admitted [DATE] with the following: Resident #49 had an order for Do Not Resuscitate (DNR)-Date initiated [DATE]. Record review of the clinical record for Resident #49 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #49 revealed the following: A DNR in Resident #49's electronic record dated [DATE] (signed by the adult child) with the following: Section-Physician Statement-there was no Physician Signature, no date of signature, no license number, and no printed signature. Section-All persons who have singed above must sign below, acknowledging that this document has bene properly completed. -There was no signature for Guardian/Agent/Proxy/Relative Signature. A DNR on the unit printed for staff to reference for Resident #49 dated [DATE] (signed by the physician) with the following: Section-Physician Statement-there was no printed signature or license number provided for the physician. During an interview on [DATE] at 03:21 PM RN A reported that if a resident coded, he would check that resident's computer profiled to determine that residents code status and that the code status could also be found at the front of the residents basic (printed) chart that was kept on the unit. RN A pulled the basic chart for Resident #23 (that he was responsible for this shift) and pointed out that the first page of the chart indicated that Resident #23 was a DNR and therefore he would not start CPR if she was coding. RN A verified that a DNR had to have completed information in order for the DNR to be active or valid. RN A reviewed Resident #23's DNR, noted that the physicians license number was missing and reported the DNR was not completed. RN A reported that if Resident #23 was to code (stop breathing or her heart stopped) at this time he would perform CPR. RN A reviewed the other 7 residents DNR's that were missing information and reported that they were also invalid and therefor if the residents were to code, he would start CPR. During an interview on [DATE] at 03:25 PM RN B (the Treatment Nurse for the facility this shift) reported that to determine a resident's code status she would check the resident's basic (printed) chart on the unit. RN B pulled Resident #49's printed DNR that was in the basic chart on the unit and noted the first page in the provided chart was a copy of Resident #49's DNR. RN B reported that Resident #49 was a DNR and therefor if the resident was not breathing or Resident #49's heart stopped, RN B would withhold CPR. When asked to review Resident #49's DNR, RN B reviewed the DNR and noted the physicians printed signature and license number were missing (unlike the DNR provided to this surveyor by the DON printed from Resident #49's electronic chart that was missing the physician signature, date, printed signature, and license number). RN B reported that due to the missing information the DNR was not valid and therefor she would have to perform CPR on Resident 49 if she coded. Resident #49 would be considered a full code (which means staff will start CPR if Resident #49 codes) until the DNR is correctly completed. RN B reviewed the 7 other residents DNR's and verified they were also missing information and were not valid until they were corrected. During an interview on [DATE] at 09:02 AM the DON reported that all residents are offered the choice for code status at admission and then the chart to include the computer and printed chart on the unit are marked as directed. The DNR is uploaded to computer once completed. The DON reported that the BDM is the one responsible for offering and completing the DNR if the resident wishes that to be their code status. The BDM is responsible for completing the DNR because she is a notary. The DON reported that he is aware of the 8 residents that have missing information on their current active DNR's and that he has already started an in-service with the nurses to correct the issue. The DON also reported that the facility has started a full review of all the residents in the system to verify their code status and the accuracy of their information. The DON reviewed the 8 residents currently listed and verified that they were all missing information on their DNR form and therefor currently had invalid DNR's. The DON reported that the facility still considered these residents to be DNR's and would not perform CPR if they coded due to knowing each resident's wishes despite the invalid DNR. When asked what the consequences of the DNR process not being completed correctly the DON stated, It does not negate the residents wishes in my mind. During an interview on [DATE] at 09:20 AM the BDM verified that she completes all the DNR interviews with each resident at admission, that she helps the resident complete their section, she then completes the section for the witness since she is a notary, then she gives the form to medical records to send to the physician to complete. She reported that she is not responsible for making sure the DNR form is complete. During an interview on [DATE] at 09:31 AM MR C verified that she received the DNR form from the BDM, she then sends the form to the physician, and when the form is returned, she checks it and puts the form in the resident's chart. MR C stated, I guess I have missed some of the information that should have been in them. I have a lot of papers that I deal with, and I don't always catch everything. MR C verified that she has not been trained on how to accurately fill out a DNR. Record review of the facility provided training dated [DATE] revealed the following: Noted incomplete OOH DNR form in EMR. Please ensure that all required areas are filled out on the OOH DNR form prior to being sent for physician signature. Record review of facility provided policy titled Do Not Resuscitate Order, revised [DATE], revealed the following: The Out of Hospital DNR Form The Out of Hospital DNR form was designed by the Texas Department of Human Services to comply with the requirement as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts. 11. All validly executed DNR orders will be honored by the facility. Record review of the facility provided policy titled Self Determination End of Life Measures, revised [DATE], revealed the following: 5. The facility will ensure compliance with the requirements of Texas law concerning appropriate health care provisions . 8. The residents right to execute and advanced directive or make changes to an existing advanced directive .will be recognized an applicable under Texas state law. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on record reviews and interviews, the facility failed to assess residents timely using the quarterly review instrument specified by the State, no later than 14 days from the ARD date for 1 of 18 residents (Resident #38) reviewed for MDS assessments. Resident #38's quarterly MDS was not completed fourteen days after the ARD date of 1/5/24. This failure can result in inadequate care and care plans not updated correctly. Findings include: Record review of Resident #38's clinical record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included but not limited to dementia (group of symptoms that affects memory, thinking and interferes with daily life), hypertension (high blood pressure), syncope and collapse (sudden loss of consciousness and muscle strength), and edema (swelling due to excess fluid). Record review of Resident #38's quarterly MDS reflected a BIMS of 07, which indicated moderate cognitive impairment. Record review of Resident #38's Quarterly MDS ARD target date began 1/5/24, reflected a completion date of 1/23/24 which indicated 18 days after the ARD date. An interview on 1/31/24 at 10:02 AM with MDS N revealed she oversaw MDS assessments. MDS N stated she has a calendar to assist with assessment schedules. MDS N revealed a MDS was completed with the RN signature. A quarterly MDS assessment was completed every 92 days and must be completed within 14 days after the ARD date. MDS N stated Resident #38's MDS ARD date was 1/5/24 and was not completed until 1/23/24. MDS N stated Resident #38's MDS was late. MDS N stated the negative outcome for not completing a quarterly MDS on time was the resident's care plan was not updated . MDS N indicated she used the RAI manual for guidance with MDS assessments. Record review of the Resident Assessment Instrument 3.0, dated October 2023, Chapter two page 24 reflected the MDS completion date must be no later than 14 days after the ARD (ARD+ 14 calendar days. This date may be earlier than or the same as the CAA(s) completion date, but not later than.

Based on interview and record review the facility failed to ensure new residents were not admitted with mental disorders, unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission for 1 of 18 residents (Resident #44) reviewed for PASRR assessments . The facility failed to ensure Resident #44 had a PASRR Level 1 screening prior to admission. This failure could place residents at risk of not obtaining services related to mental illness, intellectual or development disabilities, or developmental disabilities. Findings include: Record review of Resident #44's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44had diagnoses which included, but not limited to, Alzheimer's Disease (type of dementia that affects memory, thinking and behavior), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Record review of Resident #44's level 1 PASRR screening reflected a completed date of 7/24/23, approximately 30 days after the resident was admitted to the facility. An interview on 1/31/24 at 1:39 PM with MDS N revealed she oversaw PASRR assessments when a resident was admitted . MDS N stated PASRR identified any mental illness. MDS N was provided with the admitted Resident #44 (6/7/23). MDS N stated Resident #44's PASRR was late and didn't know how that happened. MDS N stated a negative outcome depended, but she did not feel there would be one with no PASRR prior to admission for Resident #44 since she did not have a mental illness. MDS N stated PASRR identified if the resident had a mental illness and if a resident qualified for extra services . An interview on 11/31/24 at 2:30 PM, the DON stated there was not a PASRR policy in place as the facility followed the HHSC guidelines for PASRR assessments .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (CNA D and CNA E) of 5 staff observed for resident care. -CNA D did not wash her hands or place supplies properly while performing incontinent care. -CNA E did not wash her hands while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 1-30-2024 at 09:52 AM of incontinent care performed by CNA D (Primary) with CNA E (Assisting), both CNAs were noted entering the residents room and did not wash their hands or use ABHR. CNA D removed a new brief and package of wipes from the Residents dresser and placed them directly on the resident mattress next to the resident. CNA D then put on gloves. CNA E put on gloves and removed the Residents covers. CNA D removed several wipes and placed them along with the new brief on the mattress sheets next to the resident leg. CNA D then pulled the residents brief down and cleaned the resident perineal and vaginal area with 3 separate wipes. CNA E rolled the resident to her side with CNA D's assistance. CNA D used a wipe to clean the resident's rectal area. CNA D then picked up the new brief and placed it under the resident and assisted CNA E to roll the resident to her back. CNA D finished placing/pulling up the new brief and secured it. CNA D removed her gloves for the first time since starting the procedure and placed them in the trash. CNA E removed her gloves for the first time since starting the procedure and placed them in the trash. CNA D and CNA E placed the resident in a position of comfort and exited the room. No hand hygiene was performed an anytime while in the resident's room. During an interview on 1-30-2024 at 10:00 AM CNA D and CNA E both verified that they did not perform any hand hygiene while in the room during the incontinent care. CNA E reported they did use ABHR prior to entering the room (this was not witnessed by this surveyor) but did not perform any hand hygiene while in the room performing care. Both verified that they should have performed hand hygiene to include handwashing upon entry to the room and before placing a new brief. CNA D reported that it can lead to poor hygiene for the resident, that the new brief was probably soiled. Both reported that if incontinent care is not performed correctly then a resident could develop an infection and there would be cross contamination. Both verified that not preforming hand hygiene upon completion of incontinent care and prior to leaving the room can result in carrying an infection to the next resident they provide care for. During an interview on 1-30-2024 at 02:49 PM CNA D reported that CNA E went home at 2PM and was not available. CNA D reported that her training for incontinent care and handwashing was performed by LVN F who was unavailable today and that the training was completed about a month ago. During an interview on 1-31-2024 at 09:12 AM the DON reported that he expects his staff to perform hand hygiene constantly. They should perform hand hygiene when they do any resident care, patient care, or toileting. With incontinent care they should perform hand hygiene prior to starting the care, any time they go from the dirty to clean portion of the care, and upon completion. The DON reported that staff should perform hand hygiene before exiting a resident's room especially when providing resident care to prevent the risk of cross contamination. The DON reported that If a staff members hands are soiled, they should perform handwashing, otherwise use of ABHR can suffice. The DON reported that if hand hygiene is not performed correctly then infection control will be violated and the potential for spreading infection will be great. Record review of the competency assessment titled Certified Nurse Aide Competency Verification completed for CNA D on 2-17-2023 revealed the following: Demonstrates Proficiency in performing technical procedures safely . Grooming/Hygiene B-Wash Hands-Results: Competent, experienced, . C. Observed infection control Practices; Appropriated use of PPE (gloves .)-Results: Competent, experienced, . D. Observed infection control Practices; Cross Contamination .-Results: Competent, experienced, . F. Provide Peri-Care-Results: Competent, experienced, . J. Wash Hands-Results: Competent, experienced, . -Competency Assessment: Hand Hygiene: Washing hands is the single most important thing you can do to prevent the spread of disease to yourself and others. Wash hands before and after using the restroom, after touching any body substance, after handling contaminated items, before putting on gloves, immediately after removing gloves . between all contact with persons in your care . -Signed by CNA D on 2-17-2023. Record review of the competency assessment titled Certified Nurse Aide Competency Verification completed for CNA E on 11-01-2023 revealed the following: Demonstrates Proficiency in performing technical procedures safely . Grooming/Hygiene B-Wash Hands-Results: Competent, experienced, . C. Observed infection control Practices; Appropriated use of PPE (gloves .)-Results: Competent, experienced, . D. Observed infection control Practices; Cross Contamination .-Results: Competent, experienced, . F. Provide Peri-Care-Results: Competent, experienced, . J. Wash Hands-Results: Competent, experienced, . -Competency Assessment: Hand Hygiene: Washing hands is the single most important thing you can do to prevent the spread of disease to yourself and others. Wash hands before and after using the restroom, after touching any body substance, after handling contaminated items, before putting on gloves, immediately after removing gloves . between all contact with persons in your care . -Signed by CNA E on 11-01-2023. Record review of the facility provided policy titled Perineal Care dated 12-8-2009, revealed the following: (Noted this policy was provided as part of CNA D and CNA E's competency evaluations) Procedural Guidelines: A Beginning steps. a. Wash hands B. If requires, remove all items form the residents beside table, place a barrier towel on the table, and items required to perfume care can be placed on the able. H. Wash hands and put on clean gloves for perineal care. I. Gently wash the perineal area. h. change gloves J. Cleaning the rectal and buttock area. b. gently wash the rectal and buttocks c. Change gloves K. Closing steps. a. If gloved, removed and discard gloves. Wash hands.

Based on interview and record review the facility failed to ensure that residents received treatment and care according to their policy for one (Resident #1) of eight (8) residents reviewed for quality of care. The facility failed to ensure that Resident #1 received appropriate neurological assessments after her fall with head injury on 1/31/2023. The facility did not complete neurological assessments according to their policy. This failure could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, decreased quality of life, or death. Findings include: Review of the face sheet for Resident #1 dated 2/7/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Diabetes (blood sugar disease), history of cardiac implant and graft surgery, high Cholesterol, Chronic Obstructive Pulmonary Disease (respiratory disease), and Angina (chest pain caused by reduced blood flow to the heart). Review of Resident #1's MDS, dated [DATE] reflected a BIMS score of 15, indicating resident was cognitively intact. Review of Resident #1's progress notes on 1/31/2023 at 1:45 a.m., written by RN #1, reflected the resident called the nurses station from her cell phone to tell them she had fallen and could not get back up. She has a bump rising on the top back of her head. The same notes reflected the resident's neuro assessment was within normal limits and resident had no complaints of pain or discomfort and was able to make her needs known. Record review of a progress note dated 1/31/23 at 5:08 a.m., written by RN #1, indicated Resident #1 ambulated to DR (dining room) for coffee. Gait steady, no obvious signs of pain or discomfort. Denies HA (headache) at this time. Review of Resident #1's progress notes on 1/31/2023 at 7:00 a.m., written by LNN #3, revealed resident was observed sitting in the dining room and had a change in condition. The note revealed Resident #1 was noticed slumped in a chair in the dining room and when she was questioned about what was wrong, the resident's speech was slurred, her pupils were checked and were slow to react. Resident was assessed, 911 was called to send resident to the hospital. Review of Resident #1's neurological assessments dated 1/31/2023, revealed she had assessments completed at 1:47 am, 2:30 am, 3:15 am and 4:40 am. During an interview on 2/7/2023 at 2:00 pm, the DON stated when residents fall and hit their heads, they complete neuros and monitor for change in condition. He further stated, if it is an obvious injury that needs stitches, staples, or a suspected broken bone we will send them out (to the ER). He stated he was not aware that the neuro assessment prompts in the EMR did not match the facility's policy for neuro checks. He stated he expects nurses to complete the neuro checks according to their policy, not according to the EMR. He stated this has not caused any harm to any of the residents. During an interview with RN #1 on 2/7/2023 at 2:11 pm, she stated she had completed neuro assessments on Resident #1 according to the reminders in the EMR. She stated the EMR only prompted her to complete 4 neuro assessments before the end of her shift. She stated she was familiar with the facility's policy on neuro checks and knew it started with neuro checks every 15 minutes (x4) but wasn't sure what the exact schedule was after that, she thought it might have been every hour after that and then every other hour. She stated she was unsure of the exact neuro check policy or procedure. She stated she was not aware that according to the facility's policy she should have completed 8 neuro checks on Resident #1 before the end of her shift. During an interview with LVN #2 on 2/7/2023 at 3:28 p.m., she stated when they have a fall with a suspected head injury they do a complete assessment and then start neuros. She stated when they fill out the fall report in the electronic medical record, if you select the box that states they hit their head, the EMR will prompt you to complete neuro assessments. She stated she was not sure of the timing of those prompts. She stated she believed neuro checks are supposed to be completed every 15 minutes x4, then 30 minutes x4, then 60 minutes x4 and then every shift for three days. She stated she had not had to complete a fall report in the EMR at this facility, but she had completed one at other facilities and was familiar with the process. During an interview with the AD on 2/7/2023 at 3:40 p.m., he stated it was his expectation that the nurses will be following the facility's policy regarding neuro checks. He stated it has not been a problem as far as he knows. He further stated ideally, Point Click Care (EMR) should match their policy but now I know it does not. During an interview with LVN #3 on 2/8/2023 at 10:08 a.m. she stated, they are supposed to complete neuro checks on residents that have a fall if they think they hit their head. She stated she did not rely on the EMR to cue her to complete neuro assessments. She stated neuro checks are to be completed every 15 minutes x4, every 30 minutes x2, every hour x2 and then she thought it was every 2 hours and then every shift. She stated she was not sure of the exact schedule she would have to go look it up. During an interview with the Medical Director on 2/8/23 at 10:35 a.m., she stated she was not aware that the facility policy for neuro checks did not match the EMR. She stated she did have concerns that neuro checks were not being done according to their policy, but to her knowledge this had not been a problem for any residents at the facility and she did not think it would have changed the outcome for Resident #1. She stated the facility responded appropriately when Resident #1 had a change in condition and sent her out to the ER for further care and evaluation. Review of facility policy Neurological Checks dated Rev 2/13/2007 revealed Neurological checks are a combination of objective observations and measurements done to evaluate neurologic status that includes consciousness, orientation, pupillary changes, neuromuscular function, and neurosensory perception. The results of the checks assist to determine nervous system damage and/or deterioration. Further review of this policy revealed, Frequency of checks after initial neuro check: every 15 minutes times four (x4), every 30 minutes times two (x2), one hour times two (x2), every two hours times two (x2), then every shift times 48 hours.

Based on observation, interview and record review the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one of seven residents (Resident #1) reviewed for restraints. Resident #1 was restrained in his bed with a sheet tied to the siderails to prevent him from getting out of bed. These failiures resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. These failures could effect 28 resident who are in their chair all or most of the time. Finding Include: Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission MDS dated [DATE] Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days and his ADL was extensive assistance with the assist of two people for transfers and extensive assists of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/12/13 at 6:10 PM Mills County DS stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated CNA V was arrested for elder abuse and she bonded out. He stated the other CNA and the nurse arrests were pending further investigation. DS stated the son of Resident #1 was the Chief DS of Lampasas County. DS L stated the son hid a camera in his father's room. DS stated when the resident's son saw the issues on the video he showed the Administrator of Goldthwaite Nursing and Rehab and the DON. DS was given the video by the son at the facility when the Administrator reported the abuse to the Sheriff's Department. DS went to the home of CNA V and she did state she had hit Resident #1 " to restrain him and protect herself ". DS stated CNA V and CNA X also stated they had tied the resident in his bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. Observation on 02/13/13 at 9:00 AM during tour did not reveal any resident restrained. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks "bondage marks" completely around his father's arms near his wrist the first part of January. He stated (not to long after his father was admitted ). He stated he ordered a motion activated camera because of the bruises which took about 1 ? weeks to arrive. The son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide hitting his father he called and stated he wanted to see the Administrator and the DON the next morning at nine o'clock. He stated he watched the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left his father on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet early the morning of 2/8/13. He stated the CNA hitting his father was on the early morning of the 4th. He did not look at the video until the 8th. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as something had occurred. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the room with her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Continued review of the video revealed: on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobiilty bars) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident #1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a third person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior towards staff. Observation on 02/14/13 at 6:00 AM tour no residents were observed restrained. In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor is he got out of bed and expressed her concern regarding these instructions. In an interview on 2/14/13 at 8:45 AM LVN T stated approximately two weeks ago she was standing next to CNA X when she called the DON during the night to request help CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to tie Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. In an interview on 2/14/13 at 4:55 PM CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. In an interview on 2/15/13 at 8:10 AM the DON stated she does not make random monitoring rounds on the night shift or weekends, " I live 45 minutes away " . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has " kind of been left out of the loop " . Stated " I have tried to be involved but the ADON will not let me " . She stated the " staff go to the ADON for most things; I have tried but have not gotten anywhere " . The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, " If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings " . Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated " there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her " . Stated " I did let the ADON do most everything and I am mortified " . Stated she was not aware of any abuse of Resident #1 and had never told the staff to put a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t babysit all night. She snapped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' Review of the physicians assessment report for Resident #1 dated 02/09/13 reflects: 'Assault Victim, patient examined for acute injury requiring further treatment or acute care. No x-rays indicated at this time. "I was notified by nursing home administration that Resident #1 was a victim of abuse in the nursing home. patient struck in the back by aide approximately 4 nights ago. I examined patient today with his daughter at bedside. Patient has no complaints upon questioning. Patients mental status and agitation is slowly improving as is his sleep patterns".'There were no new orders. Review of the Weekly Wound Assessment Form as a result of the investigation, signed by the DON on 02/09/13 Resident #1 had old bruising to the left lower back, yellowing in color. Scabbed areas from scratching to the lower extremities. A slight bruise noted to bilateral arms (identified as upper forearm bend of elbow and lower upper arm. The bruise to his back is at the left kidney area of the back. Review of the facility investigation dated 02/09/13 reflected CNA V, CNA X and LVN T were suspended. LVN T admitted to tying resident to his recliner and chair. CNA V and CNA X stated they had tied Resident #1 in his chair and told the police that the ADON was aware. No reports were made to the DON or the administrator. SW interviewing residents. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. Review of the facility inservices for Abuse/Neglect dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. Review of the facility Restraint Mini Manual 2003 revised February 1, 2007 MM RE 03-3.0 It is the policy of this facility to maintain an environment that prohibits the user of restraints for discipline or convenience. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/15/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver chair (online inservice program)courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for potential burnout by observing for: exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. CNA ' s will continue to make rounds Q 2 hrs. and PRN to assist with ADL care. Charge Nurses were in-served on new Q 2 hr. monitoring requirements 02/09/13 and 02/10/13. The DON or Administrator will review the Q 2 hr. nightly checks to ensure compliance and completion. 2. IDT members will be making unannounced rounds to ensure residents are safe and cared for and monitoring all staff to ensure no abuse, neglect is occurring or using restraints for convenience. The department head will also monitor staff for potential burnout. A check list will be used and completed by the department head making the unannounced round that includes: IDT will be in-serviced on the checklist with the following items. ? Sufficient staff based on resident needs assigned/present ? Staff will be interviewed regarding abuse/neglect policy by asking an abuse type question, i.e. Have you seen anyone hit or mistreat a resident, been rude to a resident, not providing proper care to a resident, etc. ? During rounds have you seen any bruising, skin tears, to the residents or is the resident acting fearful, etc. ? Resident interviews (if resident awake) to ensure all of their needs are being met. Question to be asked: Is everyone treating you well? Are they taking care of all your need? Do you feel safe and happy? ? Any other concerns identified during rounds will be noted and referred to appropriate department. ? Restraint Monitoring-i.e. ensuring any ordered restraint or device (i.e. self-release belt) for a resident, is applied correctly, that no type of restraint is applied to a resident without a physician's orders [REDACTED]. ? Any signs of potential burnout noted in staff i.e. exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. ? The department head responsible for the unannounced rounds will be given a key to the facility so they can enter the facility without alerting the staff. ? Times and dates of unannounced rounds will be staggered so staff will not know when a visit will occur. Upon completion of the monitoring checklist, the charge nurse and department head will sign and date. If any concerns regarding abuse/neglect, incidents, or restraints are identified, the Administrator will be notified immediately. 1. Completed monitoring checklists, grievances, Q 2 hour checks (from night shift charge nurses) and incident reports will be reviewed during the morning IDT and referred to the appropriate department. 2. Regional Nurse and/or Area Director of Operations will monitor for compliance of above plan. 3. All findings will be reviewed for compliance monthly. Monitoring results will be discussed and rounds will be revised as needed for safety of residents. Q 2 hour rounds by charge nurse will continue for 90 days, then will be re-evaluated and revised as needed to ensure the safety of the residents. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. The Administrator provided a facility census of 28 residents needing dependent care.

Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse for one (1) of six (6) residents reviewed for abuse/neglect when: Resident #1 was physically abused on 02/04/13 when CNA V repeated hit Resident #1 causing bruises to the back and forearms. CNA V and CNA X also tied a sheet across the resident's bed to prevent Resident #1 from getting up. On 02/08/13 Resident #1 slid from his wheelchair to the floor. Three staff members (CNA V; CNA X and LVN T) entered Resident #1's room; picked up trash from the floor, and left the room without assisting Resident #1 back to the chair or bed. Resident #1 remained on the floor for approximately 30-35 minutes. These actions were viewed on video. Staff reported possible abuse to facility administrative staff and no actions were taken. There were multiple bruises, and the resident was tearful and fearful and afraid after the incident. These failures practices resulted in an IJ and SQC on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. This failure placed 28 residents at risk for abuse who were dependent on staff for care as identified on the 672 provided by the Director of Nurses (DON). The findings include: Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission MDS dated [DATE] indicated Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days; required extensive assistance of two people for transfers; extensive assist of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks, "bondage marks", completely around his father's arms near his wrist the first part of January (not long after Resident #1 was admitted ). He stated he ordered a camera because of the bruises, which took about 1 ? weeks to arrive. He stated it was motion activated. The Son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide (CNA V) hitting his father he called and stated he wanted to see the Administrator and the DON in the morning at nine o'clock. The son stated he saw the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left Resident #1 on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet on the early morning of 02/08/13. The son stated the CNA hit his father during the early morning hours on 02/04/13. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as if something had occurred. He stated he did not look at the video until 02/08/13. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. Review of the physicians assessment report for Resident #1 dated 02/09/13 reflects: "Assault Victim, patient examined for acute injury requiring further treatment or acute care. No x-rays indicated at this time. "I was notified by nursing home administration that Resident #1 was a victim of abuse in the nursing home. Patient struck in the back by aide approximately 4 nights ago. I examined patient today with his daughter at bedside. Patient has no complaints and upon questioning. Patient's mental status and agitation is slowly improving as is his sleep patterns". There were no new orders. Review of the Weekly Wound Assessment Form, as a result of the investigation, signed by the DON on 02/09/13 Resident #1 had old bruising to the left lower back, yellowing in color. Scabbed areas from scratching to the lower extremities. A slight bruise noted to bilateral arms (identified as upper forearm bend of elbow and lower upper arm. The bruise to his back is at the left kidney area of the back. Observation on 02/13/13 at 9:00 AM on tour revealed Resident #1 up in his wheelchair. Resident #1 would only allow his shirt to be pulled up. Faint bruising was observed to the left chest wall and slight bruising was noted to the mid forearms. No other bruising was observed. the resident was smiling and there were no indication the residnet was fearful of the staff. During a second observation on Hall 2 (02/13/13 between 1:45 PM to 3:35 PM) Resident #1 the fading bruises to both forearms measuring approximately 2 by 2 inches. The coloring was light blue to greenish (fading bruises) in color at the mid forearm area. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the roomwith her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Continued review of the video revealed: on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobility bar) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident #1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a third person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior towards staff. In an interview on 02/12/13 at 6:10 PM the local DS stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated CNA V was arrested for elder abuse and later bonded out of jail. He stated the other CNA (X) and the nurse arrests were pending further investigation. The DS stated the son of Resident #1 is Chief Deputy Sheriff in another county. The DS stated the son hid a camera in Resident #1's room. The DS stated after Resident #1's son watched the video he showed the Administrator and the DON. The DS stated he was given the video by the son at the facility when the Administrator reported the abuse to the sheriff department. The DS stated he went to the home of CNA V. CNA V stated she had hit Resident #1" to restrain him and protect herself ". The DS stated CNAs V and X also stated they tied Resident #1 in bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. On 02/14/13 at 4:05 PM Deputy Sheriff played the audio recording (02/09/13) of CNA V's interview with the Sheriff's Deputy at the time of her arrest at her home. CNA V stated she did hit Resident #1 but she was trying to protect herself and restrain the resident. She did not want to see the video where she had hit the resident. She did not want to discuss what other staff that may have been told to use the sheet on Resident #1 or leave him in the floor. She did state she was told to leave him on the floor and to go in his room every 2 hours and go in only if he was awake. She then stated the DON told them (would not identify the other aide) to leave Resident #1 on the floor and to get him up before the morning crew comes on shift. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. In an interview on 02/14/13 at 4:55 PM CNA V stated she had been advised by her lawyer not to make any statements regarding Resident #1. CNA V stated working with only two nurse aides is very stressful. She stated you can not care for the other resident because Resident #1 needs constant assistance and supervision. She did stated the night the issues occurred with Resident#1 there were two aides and the nurse. While Resident #1 was acting out, there was another resident trying to leave the building, one taking off a seat belt, another pulling things off the walls and another one had fallen. CNA V stated the DON denied ever being told about issues with Resident #1. She stated she was chewed out by the DON for asking for more help. CNA V stated if Resident #1 did not need so much help and supervision then two aides could handle the floor. In an interview on 02/14/13 at 4:55 CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t ' babysit all night. She snapped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' In an earlier interview on 2/14/13 at 8:45 AM LVN T stated there are staff who are scheduled to work until 10:00 PM however they rarely stay until 10:00 PM. She stated the staff will call the DON or the person on call and request to go home early and they are allowed to go early. The DON or the on call person consults with the nurse regarding allowing staff to leave early. LVN T stated this causes problems with care because there is no coordination with the charge nurse regarding work load or resident care needs. LVN T stated approximately two weeks ago CNA X called the DON during the night; LVN T was standing next to her during this call, and requested help. CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to tie Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. In an interview on 02/14/13 at 9:55 AM LVN T stated she did go into Resident #1's room on one of those nights (02/04/13 or 02/08/13). She stated the lab person came in to draw Resident #1's blood and then CNA X and CNA V told her they had used a sheet to tie Resident #1 in his bed. The Resident #1 is up a lot during the night and he got on the floor. LVN T stated the DON denied being told they were having problems with Resident #1 and they did not have enough people to have one on one with him. LVN T stated one night she called about the issues they were having and he told her to put him on the floor on a mattress and leave him on the floor. LVN T stated CNA X did call the DON about Resident #1 being a hand full. The DON told her to use a sheet to tie him in. LVN T stated she does not remember seeing a sheet on the last night (02/08/13). LVN T stated she does not remember having an inservice on restraints. She stated she was unaware of CNA V hitting Resident #1. In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him in bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor if he got out of bed and expressed her concern regarding these instructions. In an interview on 02/13/13 at 10:45 AM the SW stated she did not know anything about the incident with Resident #1 until Saturday morning (02/09/13) which was her weekend to work. She stated a corporate person brought CNA CC in to the facility and fired her. The SW stated CNA CC told her she had reported abuse in the building and the Administrator was aware and he had done nothing. The SW stated CNA CC was the activity person and had transferred to CNA. In an interview on 02/13/13 at 11:10 AM CNA FF stated she reported to the Administrator a resident had complained of staff being rough with her on the night shift. She stated she did not know if or what was done with the report. In an interview on 02/13/13 at 3:25 PM CNA HH stated she had reported verbal abuse of a resident by CNA V to the charge nurse. She stated she then told the ADON and finally went to the Administrator. She stated the tone and actions of CNA V's statements to the resident made her consider it as verbal abuse. She stated she called the facility and spoke with the Administrator who stated he did not know anything about any reported verbal abuse. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. In an interview on 02/13/13 at 11:50 AM the Administrator stated CNA V was terminated immediately, related to the physical abuse of Resident #1. He stated CNA CC quit. He stated the SW and the Corporate Regional Nurse had spoken with CNA CC. He stated he was not aware of anyone reporting abuse. In an interview on 2/13/13 at 5:20 PM the, Vice President of Operations, revealed she had arrived at the facility on Sunday, 02/10/13. She stated she had been informed of the allegations and video on Saturday. She instructed the administrator to initiate training of the staff related to abuse/neglect. She stated the administrative team had initiated a plan of action based on what was observed in the film by the administrator and DON. Vice President of Operations stated the action plan would include a monitoring system for the off hours operation of the facility. She stated there had been no system in place for administrative monitoring of the facility prior to the notification of abuse of Resident #1 and the monitoring had not been initiated at the time of this interview. The Administrator and DON concurred with this statement. In an interview on 02/13/13 at 5:25 PM the DON stated she felt the charge nurse was ultimately responsible for what happens on their shift. She stated the Corporate Nurses has implemented managers to pop in on the night shift. She stated the night shift is from 6 PM to 6 AM and the observations would be after midnight. She stated there was no one checking on the staff on the night shift. In an interview on 02/15/13 at 8:00 AM the DON stated, "I don't know anything". she stated she was not aware that the night shift for that team needed more staff. She stated the other team who works nights have three nurse aides but no reports have been made to her. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she lives one hour away. She stated if she was called and was needed she would come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. In an interview on 2/15/13 at 8:00 AM the DON stated she does not make random monitoring rounds on the night shift or weekends, "I live 45 minutes away" . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has "kind of been left out of the loop" . Stated "I have tried to be involved but the ADON will not let me" . She stated the "staff go to the ADON for most things; I have tried but have not gotten anywhere". The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, "If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings". Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated "there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her". Stated "I did let the ADON do most everything and I am mortified". Stated she was not aware of any abuse of Resident #1 and had never told the staff to tie him with a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. In an interview on 02/15/13 at 8:40 AM the Administrator stated, "I am not aware of any thing going down". He stated he was not aware of any issues with Resident #1, not aware of the staff issues and he knew every now and then of staff calling in. He stated the DON is responsible for the nursing department. He stated the ADON did the staffing. The Administrator stated he had no expectations of anyone popping in to check on the staff until now. He stated there will be staff coming in to check. he stated he did come in this morning at 4:15 AM and asked about restraint use, asked if any falls occurred or issues during rounds. He stated Resident #1 was in bed sleeping. The Administrator stated he only lives 25 minutes away and there is no reason he can not be called. He stated he was not aware of issues revolving around CNA V and no one had called him. He stated there was a report by one staff that CNA V was being favored over the other staff so he moved CNA V to the opposite night team due to favoritism. The Administrator stated he was the abuse coordinator. In an interview on 02/15/13 at 1:15 PM the Administrator stated he did an inservice on restraints on 02/10/13 and on 02/14/13. He stated it was one on one inservice. Review of the facility investigation dated 02/09/13 reflected CNA V, CNA X and LVN T were suspended. LVN T admitted to tying resident to his recliner and chair. CNA V and CNA X stated they had tied Resident #1 in his chair and told the police that the ADON was aware. No reports were made to the DON or the administrator. SW interviewing residents. Review of the facility Abuse/Neglect Policy and Procedure dated January 8, 2003 documents: The facility will provide and ensure the promotional and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicions of abuse or neglect and situations that may constitute abuse of neglect to any resident in the facility. Under Protection states the facility will take necessary measures to protect residents and employees from harm during and following an abuse/neglect investigation. Under Prevention, number 4 documents: The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. Review of the facility inservices for Abuse/Neglect policy and procedure dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/15/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver chair (online inservice program) courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for

Based on observation, interview and record review the facility failed to develop and implement policies and procedures that prohibit abuse and neglect for one (1) of six (6) residents reviewed for abuse/neglect when: The failed to develop procedures for monitioring staff care and interactions with residents . Resident #1 was physically abused on 02/04/13 when CNA V repeated hit Resident #1 causing burises to the back and forearms. CNA V and CNA X also tied a sheet across the resident's bed to prevent Resident #1 from getting up. On 02/08/13 Resident #1 slid from his wheelchair to the floor. Three staff members (CNA V; CNA X and LVN T) entered Resident #1's room; picked up trash from the the floor, and left the room without assisting Resident #1 back to the chair or bed. Resident #1 remained on the floor for approximately 30-35 minutes. These actions were viewed on video. These failures resulted in an IJ and SQC on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. This failure placed 28 residents at risk for abuse who were dependent on staff for care as identified on the 672 provided by the Director of Nurses (DON). The findings include: Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission MDS dated [DATE] indicated Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days; required extensive assistance of two people for transfers; extensive assist of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks, "bondage marks", completely around his father's arms near his wrist the first part of January (not long after Resident #1 was admitted ). He stated he ordered a camera because of the bruises which took about 1 ? weeks to arrive. He stated it was motion activated. The Son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide (CNA V) hitting his father he called and stated he wanted to see the Administrator and the DON in the morning at nine o'clock. The son stated he saw the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left Resident #1 on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet on the early morning of 02/08/13. The son stated the CNA hit his father during the early morning hours on 02/04/13. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as if something had occurred. He stated he did not look at the video until 02/08/13. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. Review of the physicians assessment report for Resident #1 dated 02/09/13 reflects: "Assault Victim, patient examined for acute injury requiring further treatment or acute care. No x-rays indicated at this time. "I was notified by nursing home administration that Resident #1 was a victim of abuse in the nursing home. Patient struck in the back by aide approximately 4 nights ago. I examined patient today with his daughter at bedside. Patient has no complaints and upon questioning. Patient's mental status and agitation is slowly improving as is his sleep patterns". No new orders were identified. Review of the Weekly Wound Assessment Form as a result of the investigation, signed by the DON on 02/09/13 Resident #1 had old bruising to the left lower back, yellowing in color. Scabbed areas from scratching to the lower extremities. A slight bruise noted to bilateral arms (identified as upper forearm bend of elbow and lower upper arm. The bruise to his back is at the left kidney area of the back. Observation on 02/13/13 at 9:00 AM on tour revealed Resident #1 up in his wheelchair. Resident #1 would only allow his shirt to be pulled up. Faint bruising was observed to the left chest wall and slight bruising was noted to the mid forearms. No other bruising was observed. The resident was smiling and had no indication that he was afraid of staff. During a second observation on Hall 2 (02/13/13 between 1:45 PM to 3:35 PM) Resident #1 the fading bruises to both forearms measuring approximately 2 by 2 inches. The coloring was light blue to greenish in color at the mid forearm area. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the roomwith her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Continued review of the video revealed: on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobility bar) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident #1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a third person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior towards staff. In an interview on 02/12/13 at 6:10 PM the local DS stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated CNA V was arrested for elder abuse and later bonded out of jail. He stated the other CNA (X) and the nurse arrests were pending further investigation. The DS stated the son of Resident #1 is Chief Deputy Sheriff in another county. The DS stated the son hid a camera in Resident #1's room. The DS stated after Resident #1's son watched the video he showed the Administrator and the DON. The DS stated he was given the video by the son at the facility when the Administrator reported the abuse to the sheriff department. The DS stated he went to the home of CNA V. CNA V stated she had hit Resident #1" to restrain him and protect herself ". The DS stated CNAs V and X also stated they tied Resident #1 in bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. On 02/14/13 at 4:05 PM Deputy Sheriff played the audio recording (02/09/13) of CNA V's interview with the Sheriff's Deputy at the time of her arrest at her home. CNA V stated she did hit Resident #1 but she was trying to protect herself and restrain the resident. She did not want to see the video where she had hit the resident. She did not want to discuss what other staff that may have been told to use the sheet on Resident #1 or leave him in the floor. She did state she was told to leave him on the floor and to go in his room every 2 hours and go in only if he was awake. She then stated the DON told them (would not identify the other aide) to leave Resident #1 on the floor and to get him up before the morning crew comes on shift. . In an interview on 02/14/13 at 4:55 PM CNA V stated she had been advised by her lawyer not to make any statements regarding Resident #1. CNA V stated working with only two nurse aides is very stressful. She stated you can not care for the other resident because Resident #1 needs constant assistance and supervision. She did stated the night the issues occurred with Resident#1 there were two aides and the nurse. While Resident #1 was acting out, there was another resident trying to leave the building, one taking off a seat belt, another pulling things off the walls and another one had fallen. CNA V stated the DON denied ever being told about issues with Resident #1. She stated she was chewed out by the DON for asking for more help. CNA V stated if Resident #1 did not need so much help and supervision then two aides could handle the floor. In an interview on 02/14/13 at 4:55 CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t ' babysit all night. She snapped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' In an earlier interview on 2/14/13 at 8:45 AM LVN T stated there are staff who are scheduled to work until 10:00 PM however they rarely stay until 10:00 PM. She stated the staff will call the DON or the person on call and request to go home early and they are allowed to go early. The DON or the on call person consults with the nurse regarding allowing staff to leave early. LVN T stated this causes problems with care because there is no coordination with the charge nurse regarding work load or resident care needs. LVN T stated approximately two weeks ago CNA X called the DON during the night; LVN T was standing next to her during this call, and requested help. CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to tie Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. In an interview on 02/14/13 at 9:55 AM LVN T stated she did go into Resident #1's room on one of those nights (02/04/13 or 02/08/13). She stated the lab person came in to draw Resident #1's blood and then CNA X and CNA V told her they had used a sheet to tie Resident #1 in his bed. The Resident #1 is up a lot during the night and he got on the floor. LVN T stated the DON denied being told they were having problems with Resident #1 and they did not have enough people to have one on one with him. LVN T stated one night she called about the issues they were having and he told her to put him on the floor on a mattress and leave him on the floor. LVN T stated CNA X did call the DON about Resident #1 being a hand full. The DON told her to use a sheet to tie him in. LVN T stated she does not remember seeing a sheet on the last night (02/08/13). LVN T stated she does not remember having an inservice on restraints. She stated she was unaware of CNA V hitting Resident #1. In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him in bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor if he got out of bed and expressed her concern regarding these instructions. In an interview on 02/13/13 at 10:45 AM the SW stated she did not know anything about the incident with Resident #1 until Saturday morning (02/09/13) which was her weekend to work. She stated a corporate person brought CNA CC in to the facility and fired her. The SW stated CNA CC told her she had reported abuse in the building and the Administrator was aware and he had done nothing. The SW stated CNA CC was the activity person and had transferred to CNA. In an interview on 02/13/13 at 11:10 AM CNA FF stated she reported to the Administrator a resident had complained of staff being rough with her on the night shift. She stated she did not know if or what was done with the report. In an interview on 02/13/13 at 3:25 PM CNA HH stated she had reported verbal abuse of a resident by CNA V to the charge nurse. She stated she then told the ADON and finally went to the Administrator. She stated the tone and actions of CNA V's statements to the resident made her consider it as verbal abuse. She stated she called the facility and spoke with the Administrator who stated he did not know anything about any reported verbal abuse. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. In an interview on 02/13/13 at 11:50 AM the Administrator stated CNA V was terminated immediately, related to the physical abuse of Resident #1. He stated CNA CC quit. He stated the SW and the Corporate Regional Nurse had spoken with CNA CC. He stated he was not aware of anyone reporting abuse. In an interview on 2/13/13 at 5:20 PM the, Vice President of Operations, revealed she had arrived at the facility on Sunday, 02/10/13. She stated she had been informed of the allegations and video on Saturday. She instructed the administrator to initiate training of the staff related to abuse/neglect. She stated the administrative team had initiated a plan of action based on what was observed in the film by the administrator and DON. Vice President of Operations stated the action plan would include a monitoring system for the off hours operation of the facility. She stated there had been no system in place for administrative monitoring of the facility prior to the notification of abuse of Resident #1 and the monitoring had not been initiated at the time of this interview. The Administrator and DON concurred with this statement. In an interview on 02/13/13 at 5:25 PM the DON stated she felt the charge nurse was ultimately responsible for what happens on their shift. She stated the Corporate Nurses has implemented managers to pop in on the night shift. She stated the night shift is from 6 PM to 6 AM and the observations would be after midnight. She stated there was no one checking on the staff on the night shift. In an interview on 02/15/13 at 8:00 AM the DON stated, "I don't know anything". she stated she was not aware that the night shift for that team needed more staff. She stated the other team who works nights have three nurse aides but no reports have been made to her. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she lives one hour away. She stated if she was called and was needed she would come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. In an interview on 2/15/13 at 8:00 AM the DON stated she does not make random monitoring rounds on the night shift or weekends, "I live 45 minutes away" . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has "kind of been left out of the loop" . Stated "I have tried to be involved but the ADON will not let me" . She stated the "staff go to the ADON for most things; I have tried but have not gotten anywhere". The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, "If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings". Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated "there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her". Stated "I did let the ADON do most everything and I am mortified". Stated she was not aware of any abuse of Resident #1 and had never told the staff to tie him with a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. In an interview on 02/15/13 at 8:40 AM the Administrator stated, "I am not aware of any thing going down". He stated he was not aware of any issues with Resident #1, not aware of the staff issues and he knew every now and then of staff calling in. He stated the DON is responsible for the nursing department. He stated the ADON did the staffing. The Administrator stated he had no expectations of anyone popping in to check on the staff until now. He stated there will be staff coming in to check. he stated he did come in this morning at 4:15 AM and asked about restraint use, asked if any falls occurred or issues during rounds. He stated Resident #1 was in bed sleeping. The Administrator stated he only lives 25 minutes away and there is no reason he can not be called. He stated he was not aware of issues revolving around CNA V and no one had called him. He stated there was a report by one staff that CNA V was being favored over the other staff so he moved CNA V to the opposite night team due to favoritism. The Administrator stated he was the abuse coordinator. In an interview on 02/15/13 at 1:15 PM the Administrator stated he did an inservice on restraints on 02/10/13 and on 02/14/13. He stated it was one on one inservice. Review of the facility investigation dated 02/09/13 reflected CNA V, CNA X and LVN T were suspended. LVN T admitted to tying resident to his recliner and chair. CNA V and CNA X stated they had tied Resident #1 in his chair and told the police that the ADON was aware. No reports were made to the DON or the administrator. SW interviewing residents. Review of the facility Abuse/Neglect Policy and Procedure dated January 8, 2003 documents: The facility will provide and ensure the promotional and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicions of abuse or neglect and situations that may constitute abuse of neglect to any resident in the facility. Under Protection states the facility will take necessary measures to protect residents and employees from harm during and following an abuse/neglect investigation. Under Prevention, number 4 documents: The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. Review of the facility inservices for Abuse/Neglect policy and procedure dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/15/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver Chair (online inservice program) courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for potential burnout by observing for: exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. CNA ' s will continue to make rounds Q 2 hrs. and PRN to assist with ADL care. Charge Nurses

Based on observation, interview and record review the facility failed to develop and implement policies and procedures that prohibit abuse and neglect for one (1) of six (6) residents reviewed for abuse/neglect when: The failed to develop procedures for monitioring staff care and interactions with residents . Resident #1 was physically abused on 02/04/13 when CNA V repeated hit Resident #1 causing burises to the back and forearms. CNA V and CNA X also tied a sheet across the resident's bed to prevent Resident #1 from getting up. On 02/08/13 Resident #1 slid from his wheelchair to the floor. Three staff members (CNA V; CNA X and LVN T) entered Resident #1's room; picked up trash from the the floor, and left the room without assisting Resident #1 back to the chair or bed. Resident #1 remained on the floor for approximately 30-35 minutes. These actions were viewed on video. These failures resulted in an IJ and SQC on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. This failure placed 28 residents at risk for abuse who were dependent on staff for care as identified on the 672 provided by the Director of Nurses (DON). The findings include: Review of the facility Abuse/Neglect Policy and Procedure dated January 8, 2003 documents: The facility will provide and ensure the promotional and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicions of abuse or neglect and situations that may constitute abuse of neglect to any resident in the facility. Under Protection states the facility will take necessary measures to protect residents and employees from harm during and following an abuse/neglect investigation. Under Prevention, number 4 documents: The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission MDS dated [DATE] indicated Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days; required extensive assistance of two people for transfers; extensive assist of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks, "bondage marks", completely around his father's arms near his wrist the first part of January (not long after Resident #1 was admitted ). He stated he ordered a camera because of the bruises which took about 1 ? weeks to arrive. He stated it was motion activated. The Son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide (CNA V) hitting his father he called and stated he wanted to see the Administrator and the DON in the morning at nine o'clock. The son stated he saw the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left Resident #1 on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet on the early morning of 02/08/13. The son stated the CNA hit his father during the early morning hours on 02/04/13. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as if something had occurred. He stated he did not look at the video until 02/08/13. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. Review of the physicians assessment report for Resident #1 dated 02/09/13 reflects: "Assault Victim, patient examined for acute injury requiring further treatment or acute care. No x-rays indicated at this time. "I was notified by nursing home administration that Resident #1 was a victim of abuse in the nursing home. Patient struck in the back by aide approximately 4 nights ago. I examined patient today with his daughter at bedside. Patient has no complaints and upon questioning. Patient's mental status and agitation is slowly improving as is his sleep patterns". No new orders were identified. Review of the Weekly Wound Assessment Form as a result of the investigation, signed by the DON on 02/09/13 Resident #1 had old bruising to the left lower back, yellowing in color. Scabbed areas from scratching to the lower extremities. A slight bruise noted to bilateral arms (identified as upper forearm bend of elbow and lower upper arm. The bruise to his back is at the left kidney area of the back. Observation on 02/13/13 at 9:00 AM on tour revealed Resident #1 up in his wheelchair. Resident #1 would only allow his shirt to be pulled up. Faint bruising was observed to the left chest wall and slight bruising was noted to the mid forearms. No other bruising was observed. The resident was smiling and had no indication that he was afraid of staff. During a second observation on Hall 2 (02/13/13 between 1:45 PM to 3:35 PM) Resident #1 the fading bruises to both forearms measuring approximately 2 by 2 inches. The coloring was light blue to greenish in color at the mid forearm area. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the roomwith her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Continued review of the video revealed: on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobility bar) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident #1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a third person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior towards staff. In an interview on 02/12/13 at 6:10 PM the local DS stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated CNA V was arrested for elder abuse and later bonded out of jail. He stated the other CNA (X) and the nurse arrests were pending further investigation. The DS stated the son of Resident #1 is Chief Deputy Sheriff in another county. The DS stated the son hid a camera in Resident #1's room. The DS stated after Resident #1's son watched the video he showed the Administrator and the DON. The DS stated he was given the video by the son at the facility when the Administrator reported the abuse to the sheriff department. The DS stated he went to the home of CNA V. CNA V stated she had hit Resident #1" to restrain him and protect herself ". The DS stated CNAs V and X also stated they tied Resident #1 in bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. On 02/14/13 at 4:05 PM Deputy Sheriff played the audio recording (02/09/13) of CNA V's interview with the Sheriff's Deputy at the time of her arrest at her home. CNA V stated she did hit Resident #1 but she was trying to protect herself and restrain the resident. She did not want to see the video where she had hit the resident. She did not want to discuss what other staff that may have been told to use the sheet on Resident #1 or leave him in the floor. She did state she was told to leave him on the floor and to go in his room every 2 hours and go in only if he was awake. She then stated the DON told them (would not identify the other aide) to leave Resident #1 on the floor and to get him up before the morning crew comes on shift. . In an interview on 02/14/13 at 4:55 PM CNA V stated she had been advised by her lawyer not to make any statements regarding Resident #1. CNA V stated working with only two nurse aides is very stressful. She stated you can not care for the other resident because Resident #1 needs constant assistance and supervision. She did stated the night the issues occurred with Resident#1 there were two aides and the nurse. While Resident #1 was acting out, there was another resident trying to leave the building, one taking off a seat belt, another pulling things off the walls and another one had fallen. CNA V stated the DON denied ever being told about issues with Resident #1. She stated she was chewed out by the DON for asking for more help. CNA V stated if Resident #1 did not need so much help and supervision then two aides could handle the floor. In an interview on 02/14/13 at 4:55 CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t ' babysit all night. She snapped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' In an earlier interview on 2/14/13 at 8:45 AM LVN T stated there are staff who are scheduled to work until 10:00 PM however they rarely stay until 10:00 PM. She stated the staff will call the DON or the person on call and request to go home early and they are allowed to go early. The DON or the on call person consults with the nurse regarding allowing staff to leave early. LVN T stated this causes problems with care because there is no coordination with the charge nurse regarding work load or resident care needs. LVN T stated approximately two weeks ago CNA X called the DON during the night; LVN T was standing next to her during this call, and requested help. CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to time Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. In an interview on 02/14/13 at 9:55 AM LVN T stated she did go into Resident #1's room on one of those nights (02/04/13 or 02/08/13). She stated the lab person came in to draw Resident #1's blood and then CNA X and CNA V told her they had used a sheet to tie Resident #1 in his bed. The Resident #1 is up a lot during the night and he got on the floor. LVN T stated the DON denied being told they were having problems with Resident #1 and they did not have enough people to have one on one with him. LVN T stated one night she called about the issues they were having and he told her to put him on the floor on a mattress and leave him on the floor. LVN T stated CNA X did call the DON about Resident #1 being a hand full. The DON told her to use a sheet to tie him in. LVN T stated she does not remember seeing a sheet on the last night (02/08/13). LVN T stated she does not remember having an inservice on restraints. She stated she was unaware of CNA V hitting Resident #1. In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him in bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor if he got out of bed and expressed her concern regarding these instructions. In an interview on 02/13/13 at 10:45 AM the SW stated she did not know anything about the incident with Resident #1 until Saturday morning (02/09/13) which was her weekend to work. She stated a corporate person brought CNA CC in to the facility and fired her. The SW stated CNA CC told her she had reported abuse in the building and the Administrator was aware and he had done nothing. The SW stated CNA CC was the activity person and had transferred to CNA. In an interview on 02/13/13 at 11:10 AM CNA FF stated she reported to the Administrator a resident had complained of staff being rough with her on the night shift. She stated she did not know if or what was done with the report. In an interview on 02/13/13 at 3:25 PM CNA HH stated she had reported verbal abuse of a resident by CNA V to the charge nurse. She stated she then told the ADON and finally went to the Administrator. She stated the tone and actions of CNA V's statements to the resident made her consider it as verbal abuse. She stated she called the facility and spoke with the Administrator who stated he did not know anything about any reported verbal abuse. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. In an interview on 02/13/13 at 11:50 AM the Administrator stated CNA V was terminated immediately, related to the physical abuse of Resident #1. He stated CNA CC quit. He stated the SW and the Corporate Regional Nurse had spoken with CNA CC. He stated he was not aware of anyone reporting abuse. In an interview on 2/13/13 at 5:20 PM the, Vice President of Operations, revealed she had arrived at the facility on Sunday, 02/10/13. She stated she had been informed of the allegations and film on Saturday. She instructed the administrator to initiate training of the staff related to abuse/neglect. She stated the administrative team had initiated a plan of action based on what was observed in the film by the administrator and DON. Vice President of Operations stated the action plan would include a monitoring system for the off hours operation of the facility. She stated there had been no system in place for administrative monitoring of the facility prior to the notification of abuse of Resident #1 and the monitoring had not been initiated at the time of this interview. The Administrator and DON concurred with this statement. In an interview on 02/13/13 at 5:25 PM the DON stated she felt the charge nurse was ultimately responsible for what happens on their shift. She stated the Corporate Nurses has implemented managers to pop in on the night shift. She stated the night shift is from 6 PM to 6 AM and the observations would be after midnight. She stated there was no one checking on the staff on the night shift. In an interview on 02/15/13 at 8:00 AM the DON stated, "I don't know anything". she stated she was not aware that the night shift for that team needed more staff. She stated the other team who works nights have three nurse aides but no reports have been made to her. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she lives one hour away. She stated if she was called and was needed she would come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. In an interview on 2/15/13 at 8:00 AM the DON stated she does not make random monitoring rounds on the night shift or weekends, "I live 45 minutes away" . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has "kind of been left out of the loop" . Stated "I have tried to be involved but the ADON will not let me" . She stated the "staff go to the ADON for most things; I have tried but have not gotten anywhere". The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, "If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings". Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated "there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her". Stated "I did let the ADON do most everything and I am mortified". Stated she was not aware of any abuse of Resident #1 and had never told the staff to tie him with a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. In an interview on 02/15/13 at 8:40 AM the Administrator stated, "I am not aware of any thing going down". He stated he was not aware of any issues with Resident #1, not aware of the staff issues and he knew every now and then of staff calling in. He stated the DON is responsible for the nursing department. He stated the ADON did the staffing. The Administrator stated he had no expectations of anyone popping in to check on the staff until now. He stated there will be staff coming in to check. he stated he did come in this morning at 4:15 AM and asked about restraint use, asked if any falls occurred or issues during rounds. He stated Resident #1 was in bed sleeping. The Administrator stated he only lives 25 minutes away and there is no reason he can not be called. He stated he was not aware of issues revolving around CNA V and no one had called him. He stated there was a report by one staff that CNA V was being favored over the other staff so he moved CNA V to the opposite night team due to favoritism. The Administrator stated he was the abuse coordinator. In an interview on 02/15/13 at 1:15 PM the Administrator stated he did an inservice on restraints on 02/10/13 and on 02/14/13. He stated it was one on one inservice. Review of the facility investigation dated 02/09/13 reflected CNA V, CNA X and LVN T were suspended. LVN T admitted to tying resident to his recliner and chair. CNA V and CNA X stated they had tied Resident #1 in his chair and told the police that the ADON was aware. No reports were made to the DON or the administrator. SW interviewing residents. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. Review of the facility inservices for Abuse/Neglect policy and procedure dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/15/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver Chair (online inservice program) courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for potential burnout by observing for: exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. CNA ' s will continue to make rounds Q 2 hrs. and PRN to assist with ADL care. Charge Nu

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 6 residents (Resident # 1). These failiures resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. This failure could affect dependent 28 residents and place them at risk of abuse and neglect. Findings included: Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days and his Activities of Daily Living (ADL) was extensive assistance with the assist of two people for transfers and extensive assists of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/12/13 at 6:10 PM Mills County Deputy Sheriff stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated certified nurse aide (CNA) CNA V was arrested for elder abuse and she bonded out. He stated the other CNA and the nurse arrests were pending further investigation. Deputy Sheriff stated the son of Resident #1 is Chief Deputy Sheriff of Lampasas County. Deputy Sheriff stated the son hide a camera in his father's room. Deputy Sheriff stated when Chief Deputy seen issues with the video and he showed the Administrator of Goldthwaite Nursing and Rehab and the Director of Nurses (DON). Deputy Sheriff was given the video by the son at the facility when the Administrator reported the abuse to the sheriff department. Deputy Sheriff went to the home of CNA V and she did state she had hit Resident #1 "to restrain him and protect herself". Deputy Sheriff stated CNA V and CNA X also stated they had tied the resident in his bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. Observation on 02/13/13 at 9:00 AM on tour revealed no bruises of unknown causes. Resident #1 was up in his wheelchair and allow his shirt to be pulled up only. There was faint bruising to the left chest wall. The mid forearms had slight bruising noted. the resident was smiling with no indication that he was afraid or fearful of the staff. In an interview on 02/13/13 at 11:50 AM the Administrator stated CNA V was terminated immediately related to the physical abuse of Resident #1. He stated CNA CC she quit. He stated the Social Worker and the Corporate Regional Nurse had spoken with CNA CC. He stated he was not aware of anyone reporting abuse or short of staff. Observation rounds of Hall 2 on 02/13/13 at 1:45 PM to 3:35 PM revealed no major bruising of unknown causes for all residents, but Resident #1. Resident #1 had fading bruises to both forearms measuring approximately 2 by 2 inches. The coloring was light blue to greenish in color at the mid forearm area. Observation on 0 02/13/13 at 3:45 PM of Resident #1 receiving a shower revealed the resident had the same bruising as noted before. The son provided consent and the resident agreed to allow pictures to be taken. During the taking of pictures, the resident was frequently resistant to positioning. The resident was noted to have a red buttocks expanding out from the anus to the area of the imprinted shower chair opening. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks " bondage marks " completely around his father's arms near his wrist the first part of January (not to long after his father was admitted ). He stated he ordered a camera because of the bruises, which took about 1 ? weeks to arrive. He stated it was motion activated. The Son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide hitting his father he called and stated he wanted to see the Administrator and the DON in the morning at nine o'clock. The son stated he saw the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left his father on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet on the early morning of the 8th. The son stated the CNA hitting his father was on the early morning of the 4th. He did not look at the video until the 8th. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as something had occurred. In an interview on 2/13/13 at 5:20 PM the, Vice President of Operations, revealed she had arrived at the facility on Sunday, 02/10/13. She stated she had been informed of the allegations and video on Saturday. She instructed the administrator to initiate training of the staff related to abuse/neglect. She stated the administrative team had initiated a plan of action based on what was observed in the film by the administrator and DON. Vice President of Operations stated the action plan would include a monitoring system for the off hours operation of the facility. She stated there had been no system in place for administrative monitoring of the facility prior to the notification of abuse of Resident #1 and the monitoring had not been initiated at the time of this interview. The Administrator and DON concurred with this statement. In an interview on 02/13/13 at 5:25 PM the DON stated she felt the charge nurse was ultimately responsible for what happens on their shift. She stated the Corporate Nurses has implemented managers to pop in on the night shift. She stated the night shift is from 6 PM to 6 AM and the observations would be after midnight. She stated there was no one checking on the staff on the night shift. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the roomwith her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Further review of the video on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobility bar) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident # 1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a fourth person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior. In an interview on 02/14/13 at 9:55 AM LVN T stated she did go into Resident #1's room on one of those nights (02/04/13 or 02/08/13). She stated the lab person came in to draw Resident #1's blood and then CNA X and CNA V told her they had used a sheet to tie Resident #1 in his bed. The Resident #1 is up a lot during the night and he got on the floor. LVN T stated the DON denied being told they were having problems with Resident #1 and they did not have enough people to have one on one with him. LVN T stated one night she called about the issues they were having and he told her to put him on the floor on a mattress and leave him on the floor. LVN T stated CNA X did call the DON about Resident #1 being a hand full. The DON told her to use a sheet to tie him in. LVN T stated she does not remember seeing a sheet on the last night (02/08/13). LVN T stated she does not remember having an inservice on restraints. She stated she was unaware of CNA V hitting Resident #1. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. On 02/14/13 at 4:05 PM Deputy Sheriff played the audio recording (02/09/13) of CNA V's interview with the Sheriff's Deputy at the time of her arrest at her home. CNA V stated she did hit Resident #1 but she was trying to protect herself and restrain the resident. She did not want to see the video where she had hit the resident. She did not want to discuss what nurse or aide was told to use the sheet on Resident #1 or leave him in the floor. She did state she was told to leave him on the floor and to go in his room every 2 hours and not to go in there only if he was awake. She then stated the DON told them (would not identify the other aide) to leave Resident #1 on the floor and to get him up before the morning crew comes on shift. In an interview on 02/14/13 at 4:55 PM CNA V stated she had been advised by her lawyer not to make any statements regarding Resident #1. CNA V stated working with only two nurse aides is very stressful. She stated you cannot care for the other resident because Resident #1 needs constant assistance and supervision. She did stated the night the issues occurred with Resident#1 there were two aides and the nurse. While Resident #1 was acting out, there was another resident trying to leave the building, one taking off a seat belt, another pulling thing off the walls and another one had fallen. CNA V stated the DON denied ever being told about issues with Resident #1. She stated she was chewed out by the DON for asking for more help. CNA V stated if Resident #1 did not need so much help and supervision then two aides could handle the floor. In an interview on 2/14/13 at 4:55 PM CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t babysit all night. She snaped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor is he got out of bed and expressed her concern regarding these instructions. In an interview on 2/14/13 at 8:45 AM LVN T stated there are staff who are scheduled to work until 10:00 PM however they rarely stay until 10:00 PM. She stated the staff will call the DON or the person on call and request to go home early and they are allowed to go early. The DON or the on call person consults with the nurse regarding allowing staff to leave early. LVN T stated this causes problems with care because there is no coordination with the charge nurse regarding work load or resident care needs. LVN T stated approximately two weeks ago CNA X called the DON during the night; LVN T was standing next to her during this call, and requested help. CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to tie Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. In an interview on 02/15/13 at 8:00 AM the DON stated, "I don't know anything". She stated she was not aware that the night shift, that team needed more staff. She stated the other team who works nights have three nurse aides but no reports have been made to her. She stated there were people who are on call but she did not call anyone. She stated that was up to the ADON as she does staffing. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she live one hour away. She stated if she was called and needed she would have come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. The DON stated she lives one hour away and she does not come in on nights to check. In an interview on 2/15/13 at 8:10 AM the DON stated "I don't know anything". She stated does not make random monitoring rounds on the night shift or weekends, " I live 45 minutes away " . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has " kind of been left out of the loop " . Stated " I have tried to be involved but the ADON will not let me " . She stated the " staff go to the ADON for most things; I have tried but have not gotten anywhere " . The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, " If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings " . Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated " there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her " . Stated " I did let the ADON do most everything and I am mortified " . Stated she was not aware of any abuse of Resident #1 and had never told the staff to put a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she lives one hour away. She stated if she was called and was needed she would come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. In an interview on 02/15/13 at 8:40 AM the Administrator stated, "I am not aware of any thing going down". He stated he was not aware of any issues with Resident #1, not aware of the staff issues and he knew every now and then of staff calling in. He stated the DON is responsible for the nursing department. He stated the ADON did the staffing. The Administrator stated he had no expectations of anyone popping in to check on the night shift until now. He stated there will be staff coming in to check. He stated he did come in this morning at 4:15 AM and asked about restraint use, asked if any falls occurred or issues during rounds. He stated Resident #1 was in bed sleeping. The Administrator stated he only lives 25 minutes away and there is no reason he cannot be called. He stated he was not aware of issues revolving around CNA V and no one had called him. He stated there was a report by one staff that CNA V was being favored over the other staff so he moved CNA V to the opposite night team due to favoritism. Review of the facility inservices for Abuse/Neglect dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. Review of the facility Abuse/Neglect Policy and Procedure dated January 8, 2003 documents: The facility will provide and ensure the promotional and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicions of abuse or neglect and situations that may constitute abuse of neglect to any resident in the facility. Under Protection states the facility will take necessary measures to protect residents and employees from harm during and following an abuse/neglect investigation. Under Prevention, number 4 documenters: The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/14/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver chair courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for potential burnout by observing for: exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. CNA ' s will continue to make rounds Q 2 hrs. and PRN to assist with ADL care. Charge Nurses were in-served on new Q 2 hr. monitoring requirements 02/09/13 and 02/10/13. The DON or Administrator will review the Q 2 hr. nightly checks to ensure compliance and completion. 2. IDT members will be making unannounced rounds to ensure residents are safe and cared for and monitoring all staff to ensure no abuse, neglect is occurring or using restraints for convenience. The department head will also monitor staff for potential burnout. A check list will be used and completed by the department head making the unannounced round that includes: IDT will be in-serviced on the checklist with the following items. ? Sufficient staff based on resident needs assigned/present ? Staff will be interviewed regarding abuse/neglect policy by asking an abuse type question, i.e. Have you seen anyone hit or mistreat a resident, been rude to a resident, not providing proper care to a resident, etc. ? During rounds have you seen any bruising, skin tears, to the residents or is the resident acting fearful, etc. ? Resident interviews (if resident awake) to ensure all of their needs are being met. Question to be asked: Is everyone treating you well? Are they taking care of all your need? Do you feel safe and happy? ? Any other concerns identified during rounds will be noted and referred to appropriate department. ? Restraint Monitoring-i.e. ensuring any ordered restraint or device (i.e. self-release belt) for a resident, is applied correctly, that no type of restraint is applied to a resident without a physician's orders [REDACTED]. ? Any signs of potential burnout noted in staff i.e. exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. ? The department head responsible for the unannounced rounds will be given a key to the facility so they can enter the facility without alerting the staff. ? Times and dates of unannounced rounds will be staggered so staff will not know when a visit will occur. Upon completion of the monitoring checklist, the charge nurse and d

Based on observation, interview and record review the facility failed to develop and implement policies and procedures that prohibit abuse and neglect for one (1) of six (6) residents reviewed for abuse/neglect when: The failed to develop procedures for monitioring staff care and interactions with residents . Resident #1 was physically abused on 02/04/13 when CNA V repeated hit Resident #1 causing burises to the back and forearms. CNA V and CNA X also tied a sheet across the resident's bed to prevent Resident #1 from getting up. On 02/08/13 Resident #1 slid from his wheelchair to the floor. Three staff members (CNA V; CNA X and LVN T) entered Resident #1's room; picked up trash from the the floor, and left the room without assisting Resident #1 back to the chair or bed. Resident #1 remained on the floor for approximately 30-35 minutes. These actions were viewed on video. These failures resulted in an IJ and SQC on 02/14/13. While the IJ was removed on 02/15/13 the facility remained out of compliance at a level of Actual Harm at a Pattern. This failure placed 28 residents at risk for abuse who were dependent on staff for care as identified on the 672 provided by the Director of Nurses (DON). The findings include: Review of the face sheet for Resident #1 reflected the following information: Resident #1 was admitted on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #1's birth date was 09/12/26. He received the following medications: [REDACTED]. Review of the admission MDS dated [DATE] indicated Resident #1 had cognitive impairment, behaviors consisting of physical behaviors toward others occurring in 1 to 3 days; required extensive assistance of two people for transfers; extensive assist of one person for dressing, and eating. Resident #1 was not ambulatory and used a wheelchair for mobility. Review of the Comprehensive Care Plan completed with the Admission MDS dated [DATE] reflected Resident #1 had listed: -Behaviors identified as agitation with approaches list as: monitor for early warning signs of behaviors approach in a calm manner, call by name remove from unwanted stimuli. -Incontinent of bowel and bladder with approaches listed as: monitor incontinent every 2 hours/as needed, change promptly; and apply protective skin barrier to skin, monitor for signs and symptom of skin break down, report to physician and responsible party, assess for possible toileting program and at risk for skin breakdown. -Impaired communication with approaches listed as: reduce or remove all interfering environmental stimuli, use commutation tools, terms, gestures the resident can understand, approach in a calm manner using eye contact, call by name, and allow time for resident to digest information--do not rush. -History of falls with approaches listed as, bed and chair alarms, low bed, mat on floor, bolsters and scoop mattress, area free of clutter, monitor for proper body alignment, encourage and monitor for continued independence offer assistance as needed, encourage socialization and activities, call light in reach, therapy to screen and treat per orders, anticipate needs, provide prompt assistance, area is lit adequately, proper foot wear and appropriate assuasive devices are used as ordered. -Alzheimer's/Dementia with approaches as listed: administer meds per orders, monitor of adverse reactions and side effects, explain all procedures using simple one word commands if possible, Pleasant interaction which assures resident when confused, provide cueing and prompting for personal care, attempt to have resident initiate the activity you want them to perform, observe for signs and symptoms of frustration/anxiety and change activity as indicated, Involve in low stress (low expectation) activities such as small group activities, if resident is combative use only enough force to protect self and avoid injury to resident, avoid being aggressive in approaching resident, encourage resident to participate in activities of daily living, remove resident from upsetting stimuli to avoid intensifying aggressive behaviors, plan frequent rest periods but assure there are not long periods of inactivity, use task segmentation, encourage active participation in choice of wardrobe, meal activity and allow decision making as often as possible, praise resident for making decisions, and notify physician and family of changes, -Anxious with approaches as listed: keep call light, water and personal itemms within reach, visualize and reassure resident every 2 hours during rounds and as needed at each eipisoe, 1on 1 with staff for redirection, comfort and reassurance as needed during times of incrased anxiety and restlessness, encourage socialiation with staff and other residetns out of room, provide activity calendar, and remind resident daily of activity times, encourage attencane , encourage family to visit, administer antianxiety meds as ordered and monitor of effectiveneess, notify physicanian and family as needed refer to social services as needed. -Also Resident #1 had a care plan addressing : - a history of [MEDICAL CONDITION], hypertension, refuses medications, resist care with episodes of being combative, at risk for skin breakdown, self care deficit, assist with ADL's with two people to transfer, potential for altered comfort, cognitive impairment, therapeutic diet, activities, restorative care, elopement risk and at risk for dehydration. In an interview on 02/13/13 at 4:10 PM the son of Resident #1 stated when he visited he noticed big black marks, "bondage marks", completely around his father's arms near his wrist the first part of January (not long after Resident #1 was admitted ). He stated he ordered a camera because of the bruises which took about 1 ? weeks to arrive. He stated it was motion activated. The Son stated he would remove the chip from the camera every couple of days and review the video. He stated after reviewing the nurse aide (CNA V) hitting his father he called and stated he wanted to see the Administrator and the DON in the morning at nine o'clock. The son stated he saw the video on 02/08/13 and spoke with the Administrator on 02/09/13. He stated they left Resident #1 on the floor for 30 to 35 minutes and also had tied him in his bed with a bed sheet on the early morning of 02/08/13. The son stated the CNA hit his father during the early morning hours on 02/04/13. He stated he had come on Saturday (02/06/13) after lunch and his father was visibly upset as if something had occurred. He stated he did not look at the video until 02/08/13. He stated he found his father naked in his bed with feces on the floor. The son stated the physician came the next day and checked his father out. There were evidence of bruising on Resident #1's back, forearms, and scraps to the lower legs. Review of the physicians assessment report for Resident #1 dated 02/09/13 reflects: "Assault Victim, patient examined for acute injury requiring further treatment or acute care. No x-rays indicated at this time. "I was notified by nursing home administration that Resident #1 was a victim of abuse in the nursing home. Patient struck in the back by aide approximately 4 nights ago. I examined patient today with his daughter at bedside. Patient has no complaints and upon questioning. Patient's mental status and agitation is slowly improving as is his sleep patterns". No new orders were identified. Review of the Weekly Wound Assessment Form as a result of the investigation, signed by the DON on 02/09/13 Resident #1 had old bruising to the left lower back, yellowing in color. Scabbed areas from scratching to the lower extremities. A slight bruise noted to bilateral arms (identified as upper forearm bend of elbow and lower upper arm. The bruise to his back is at the left kidney area of the back. Observation on 02/13/13 at 9:00 AM on tour revealed Resident #1 up in his wheelchair. Resident #1 would only allow his shirt to be pulled up. Faint bruising was observed to the left chest wall and slight bruising was noted to the mid forearms. No other bruising was observed. The resident was smiling and had no indication that he was afraid of staff. During a second observation on Hall 2 (02/13/13 between 1:45 PM to 3:35 PM) Resident #1 the fading bruises to both forearms measuring approximately 2 by 2 inches. The coloring was light blue to greenish in color at the mid forearm area. Review 02/13/13 at 6:00 PM of a CD video provided by the local DS who received the video from the son of Resident # 1 which reflected: On 02/04/13 at 4:07 AM reflected CNA V hit Resident #1 three times. Once in the back and the other two times her arm was visible swinging at him but the area of the strike was not clearly visible. CNA V was pulling roughly (pulled and tugged) on Resident #1 while she provided incontinent care and then threw an unidentified object in Resident #1's face. There was no audio with the video, however CNA V was observed swinging her arms and her mouth was moving and head shaking at Resident #1. At 4:17 AM CNA V was observed pushing Resident #1 down roughly twice onto the bed while he was on his stomach and trying to get up.CNA V's body was blocking the face of Resident #1. Somewhere between 4:17 AM and 4:25 AM the resident was placed in his wheelchair and he slid to the floor. At 4:25 AM Resident #1 was noted on the floor in the video when CNA X came into the roomwith her cell phone to her ear and then turned around and walked back out leaving the resident on the floor. The resident preceded to empty the trash can onto the floor with wet briefs and feces in the trash can. At 4:30 AM CNA V came back into the room with LVN T (charge nurse). CNA X also came in and all were cleaning up the trash from the floor and cleaning the floor with wipes. At 4:32 AM CNA V wiped down Resident #1 ' s bed while the resident was lying on the floor. At 5:08 AM Resident #1 was still on the floor moving around and staff had not attempted to assist Resident #1 back to bed. Continued review of the video revealed: on 02/08/13 at 1:22 AM Resident #1 was tied to his bed with a sheet. The bed had small enabler type rails (mobility bar) that CNA V and CNA X tied the sheet to. The sheet was tied across Resident #1's chest from rail enabler to rail enable cinching tightly and pulled Resident #1's privacy curtain part way closed. At 2:08 AM a third person was observed which was determined to be the lab technician drawing blood. As soon as the lab Technician left the room CNA V and CNA X tied the sheet back to the rail enabler. Resident #1 was observed on the video pulling and tugging on his sheet. At 2:45 AM Resident #1 worked the sheet loose from the rail enabler and CNA X retied the sheet. At 4:25 AM CNA's retied the sheets. At 4:30 AM Resident #1 was sitting in a recliner chair. There was no further video. At no time did Resident #1 demonstrate combative or resistant behavior towards staff. In an interview on 02/12/13 at 6:10 PM the local DS stated the video of Resident #1 being hit and left in the floor for long periods of time along with the resident being tied to his bed with a sheet was very disturbing. He stated CNA V was arrested for elder abuse and later bonded out of jail. He stated the other CNA (X) and the nurse arrests were pending further investigation. The DS stated the son of Resident #1 is Chief Deputy Sheriff in another county. The DS stated the son hid a camera in Resident #1's room. The DS stated after Resident #1's son watched the video he showed the Administrator and the DON. The DS stated he was given the video by the son at the facility when the Administrator reported the abuse to the sheriff department. The DS stated he went to the home of CNA V. CNA V stated she had hit Resident #1" to restrain him and protect herself ". The DS stated CNAs V and X also stated they tied Resident #1 in bed with a bed sheet. CNA X stated she was told by the DON over the phone they could tie Resident #1 to the rails with a sheet as long as they did not tie his hands. On 02/14/13 at 4:05 PM Deputy Sheriff played the audio recording (02/09/13) of CNA V's interview with the Sheriff's Deputy at the time of her arrest at her home. CNA V stated she did hit Resident #1 but she was trying to protect herself and restrain the resident. She did not want to see the video where she had hit the resident. She did not want to discuss what other staff that may have been told to use the sheet on Resident #1 or leave him in the floor. She did state she was told to leave him on the floor and to go in his room every 2 hours and go in only if he was awake. She then stated the DON told them (would not identify the other aide) to leave Resident #1 on the floor and to get him up before the morning crew comes on shift. . In an interview on 02/14/13 at 4:55 PM CNA V stated she had been advised by her lawyer not to make any statements regarding Resident #1. CNA V stated working with only two nurse aides is very stressful. She stated you can not care for the other resident because Resident #1 needs constant assistance and supervision. She did stated the night the issues occurred with Resident#1 there were two aides and the nurse. While Resident #1 was acting out, there was another resident trying to leave the building, one taking off a seat belt, another pulling things off the walls and another one had fallen. CNA V stated the DON denied ever being told about issues with Resident #1. She stated she was chewed out by the DON for asking for more help. CNA V stated if Resident #1 did not need so much help and supervision then two aides could handle the floor. In an interview on 02/14/13 at 4:55 CNA X stated after the third CNA scheduled for the night shift resigned in the middle of December 2012 she and CNA V had given several notes to the DON requesting help and expressing their concern regarding their inability to provide the level of care for Resident #1 and provide care to the other residents. She further stated early in February 2013 she called the DON around 12:00 AM asking for help because it was taking both CNAs to care for Resident #1. She stated she, CNA V and LVN T were standing at the nurse ' s station when she made the call and heard what she said to the DON. CNA X stated when she asked the DON for help she said " What the hell do you want me to do I am in Brownwood. No one is going to come in so you will just have to deal with it " . She stated the DON told her if Resident #1 would not stay in bed to leave him on the floor or she could use sheets to tie him in bed as long as she did not tie his hands it would not be considered a restraint. CNA X stated she tied a sheet to the hand rails across Resident #1 ' s body to remind him not to get out of bed. Review of a written statement by CNA X dated 2/14/13 reflected the following: ' On one of the nights we, LVN T, CNA V and myself) having trouble with Resident #1 I called the DON and asked for help, meaning and explaining to her we need help by a third aid. I explained to her he was one on one and with there only being two aides and one nurse we couldn ' t ' babysit all night. She snapped at me telling me ' What the hell do you want me to do, I ' m in Brownwood, call someone in " . I told her no one was gonna come in and that I couldn ' t handle it if it was just gonna be two of us on nights ... She then told me to keep him in his chair as long as we didn ' t physically tie his hands down. I looked at my charge nurse (LVN T) who was standing right beside me and just hung up the phone. I told LVN T exactly what the DON said ... By the time we completed our rounds on one hall Resident #1 would not stay in his seat or bed. We had a resident fall and couldn ' t tend to her without leaving Resident #1 unattended, so with what the DON telling me playing in my head I laced a sheet across the rails of Resident #1 ' s bed, with only the intention of keeping from getting up and falling while we were on the other hall. ' In an earlier interview on 2/14/13 at 8:45 AM LVN T stated there are staff who are scheduled to work until 10:00 PM however they rarely stay until 10:00 PM. She stated the staff will call the DON or the person on call and request to go home early and they are allowed to go early. The DON or the on call person consults with the nurse regarding allowing staff to leave early. LVN T stated this causes problems with care because there is no coordination with the charge nurse regarding work load or resident care needs. LVN T stated approximately two weeks ago CNA X called the DON during the night; LVN T was standing next to her during this call, and requested help. CNA X explained to the DON it was taking two people to care for Resident #1 which left no one to provide care for the other residents. When the call ended CNA X told LVN T the DON had yelled at her that no one was going to come in to help and what did they want her to do. She further stated CNA X told her the DON told her to use a sheet to time Resident #1 in bed, that as long as they did not tie his hands it was not considered a restraint. In an interview on 02/14/13 at 9:55 AM LVN T stated she did go into Resident #1's room on one of those nights (02/04/13 or 02/08/13). She stated the lab person came in to draw Resident #1's blood and then CNA X and CNA V told her they had used a sheet to tie Resident #1 in his bed. The Resident #1 is up a lot during the night and he got on the floor. LVN T stated the DON denied being told they were having problems with Resident #1 and they did not have enough people to have one on one with him. LVN T stated one night she called about the issues they were having and he told her to put him on the floor on a mattress and leave him on the floor. LVN T stated CNA X did call the DON about Resident #1 being a hand full. The DON told her to use a sheet to tie him in. LVN T stated she does not remember seeing a sheet on the last night (02/08/13). LVN T stated she does not remember having an inservice on restraints. She stated she was unaware of CNA V hitting Resident #1. In an interview on 2/14/13 at 6:30 AM LVN S stated LVN T called her one night early in February 2013 and stated she had concerns regarding Resident #1 ' s behavior, she could not keep him in bed and there was not enough staff to stay with him and take care of the other residents. She further stated LVN T told her she had called the DON and was told to leave Resident #1 on the floor if he got out of bed and expressed her concern regarding these instructions. In an interview on 02/13/13 at 10:45 AM the SW stated she did not know anything about the incident with Resident #1 until Saturday morning (02/09/13) which was her weekend to work. She stated a corporate person brought CNA CC in to the facility and fired her. The SW stated CNA CC told her she had reported abuse in the building and the Administrator was aware and he had done nothing. The SW stated CNA CC was the activity person and had transferred to CNA. In an interview on 02/13/13 at 11:10 AM CNA FF stated she reported to the Administrator a resident had complained of staff being rough with her on the night shift. She stated she did not know if or what was done with the report. In an interview on 02/13/13 at 3:25 PM CNA HH stated she had reported verbal abuse of a resident by CNA V to the charge nurse. She stated she then told the ADON and finally went to the Administrator. She stated the tone and actions of CNA V's statements to the resident made her consider it as verbal abuse. She stated she called the facility and spoke with the Administrator who stated he did not know anything about any reported verbal abuse. In an interview on 02/14/13 at 12:00 PM ADON stated she had reported CNA V using verbal abuse when caring for residents. She stated she reported it to the Administrator. She was overheard saying to someone she wondered if the Administrator did an investigation of the report of CNA V using verbal abuse. She was called in to the office in front of the DON and corporate nurse and the Administrator and was suspended. ADON stated she was notified of the alleged abuse in the evening but she did not notify the Administrator until the next day when she was called into the office the next morning. She stated corporate has been called multiple times by the staff reporting abuse that was not investigated by the Administrator or DON and faxes and reports have been sent. ADON stated she believes if the allegations were investigated then the issues with physical abuse may not have occurred. She stated that at least three other staff have reported abuse and nothing was done. These people are suspended or fired. She stated she was not aware of Resident #1 being tied to the bed with a sheet. In an interview on 02/13/13 at 11:50 AM the Administrator stated CNA V was terminated immediately, related to the physical abuse of Resident #1. He stated CNA CC quit. He stated the SW and the Corporate Regional Nurse had spoken with CNA CC. He stated he was not aware of anyone reporting abuse. In an interview on 2/13/13 at 5:20 PM the, Vice President of Operations, revealed she had arrived at the facility on Sunday, 02/10/13. She stated she had been informed of the allegations and film on Saturday. She instructed the administrator to initiate training of the staff related to abuse/neglect. She stated the administrative team had initiated a plan of action based on what was observed in the film by the administrator and DON. Vice President of Operations stated the action plan would include a monitoring system for the off hours operation of the facility. She stated there had been no system in place for administrative monitoring of the facility prior to the notification of abuse of Resident #1 and the monitoring had not been initiated at the time of this interview. The Administrator and DON concurred with this statement. In an interview on 02/13/13 at 5:25 PM the DON stated she felt the charge nurse was ultimately responsible for what happens on their shift. She stated the Corporate Nurses has implemented managers to pop in on the night shift. She stated the night shift is from 6 PM to 6 AM and the observations would be after midnight. She stated there was no one checking on the staff on the night shift. In an interview on 02/15/13 at 8:00 AM the DON stated, "I don't know anything". she stated she was not aware that the night shift for that team needed more staff. She stated the other team who works nights have three nurse aides but no reports have been made to her. The DON stated she has only been in the building on the night shift one time since she started in April 2012 and that was to work the shift. She stated she does not pop in to see how things are going as she lives one hour away. She stated if she was called and was needed she would come in. She stated there has been hot line calls to corporate complaining about her especially after she wrote up a medication aide working on the day shift. In an interview on 2/15/13 at 8:00 AM the DON stated she does not make random monitoring rounds on the night shift or weekends, "I live 45 minutes away" . She further stated no one is assigned to come in to make rounds. She stated since coming to the facility she has "kind of been left out of the loop" . Stated "I have tried to be involved but the ADON will not let me" . She stated the "staff go to the ADON for most things; I have tried but have not gotten anywhere". The DON stated she has not received any requests for additional staffing or help. She stated when Resident #1 was admitted to the facility he was very combative however have not had any of these behaviors for several weeks, mostly just gets out of bed or his wheelchair. Stated the MDS Coordinator is responsible for the care planning for residents. The DON stated she does not always go to the care plan meetings, "If we know there are any issues, the MDS Coordinator will ask me to sit in on the care plan meetings". Stated the DON is responsible for developing and implementing plans of care for residents. The DON stated "there should have been 3 CNAs on the night shift, but the ADON does the staffing so I left all that up to her". Stated "I did let the ADON do most everything and I am mortified". Stated she was not aware of any abuse of Resident #1 and had never told the staff to tie him with a sheet on him. She stated she had told the staff to put a mat on the floor and if he got out of bed and lay on the mat to leave him there. In an interview on 02/15/13 at 8:40 AM the Administrator stated, "I am not aware of any thing going down". He stated he was not aware of any issues with Resident #1, not aware of the staff issues and he knew every now and then of staff calling in. He stated the DON is responsible for the nursing department. He stated the ADON did the staffing. The Administrator stated he had no expectations of anyone popping in to check on the staff until now. He stated there will be staff coming in to check. he stated he did come in this morning at 4:15 AM and asked about restraint use, asked if any falls occurred or issues during rounds. He stated Resident #1 was in bed sleeping. The Administrator stated he only lives 25 minutes away and there is no reason he can not be called. He stated he was not aware of issues revolving around CNA V and no one had called him. He stated there was a report by one staff that CNA V was being favored over the other staff so he moved CNA V to the opposite night team due to favoritism. The Administrator stated he was the abuse coordinator. In an interview on 02/15/13 at 1:15 PM the Administrator stated he did an inservice on restraints on 02/10/13 and on 02/14/13. He stated it was one on one inservice. Review of the facility investigation dated 02/09/13 reflected CNA V, CNA X and LVN T were suspended. LVN T admitted to tying resident to his recliner and chair. CNA V and CNA X stated they had tied Resident #1 in his chair and told the police that the ADON was aware. No reports were made to the DON or the administrator. SW interviewing residents. Review of the facility Abuse/Neglect Policy and Procedure dated January 8, 2003 documents: The facility will provide and ensure the promotional and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicions of abuse or neglect and situations that may constitute abuse of neglect to any resident in the facility. Under Protection states the facility will take necessary measures to protect residents and employees from harm during and following an abuse/neglect investigation. Under Prevention, number 4 documents: The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. On 02/14/13 at 4:50 PM the Administrator was notified an IJ was identified due to the above deficient practice. Review of the facility inservices for Abuse/Neglect policy and procedure dated 01/29/13, 02/09/13 and staff question on who the abuse coordinator was dated 02/10/13 reflected CNA V had not attending any of the inservices. CNA X attended the 01/29/13 inservice but not the other two. LVN T had not attended any of the inservices provided. There was an inservice on restraints dated 02/10/13 through 02/14/13 which none of the night crew (CNA V AND X and LVN T) did not attend. The following Plan of Removal was submitted by the Administrator on 02/15/13 at 5:15 PM. The final Plan of Removal was accepted by the investigator on 02/15/13 at 5:35 PM. Plan of Removal Problems Identified: Failure to protect residents from abuse. Failure to appropriately supervise night shift. Residents restrained without medical necessity. Allowing residents to remain on the floor. Residents Affected: Resident's dependent on staff for ADL's has the potential to be affected by this alleged deficient practice. Systemic Changes: 1. Police notified immediately (02/09/13 at approximately 10 AM). 2. Employees with suspected involvement suspended (02/09/13). 3. Staff in-serviced on Abuse/Neglect, restraints, and behavior management 02/09-02/19/13. a. The abuse in-service consisted of types, prevention, identification, and reporting. ? Types of abuse-verbal, physical, sexual, mental, neglect, exploitation, mistreatment, seclusion. ? Prevention-through staff education related to abuse/neglect. ? Identification-through actual observation of an abusive situation, or potential abuse as observed by unknown injuries i.e. bruise, skin tear, fracture, or by any allegation of abuse. ? Reporting-To report abuse/neglect or suspected abuse/neglect to the Task 5 G coordinator immediately. In this facility the task 5G coordinator is the administrator. b. The restraint in-service consist of the following: ? Definition of a restraint-any device or method that prevents a resident from normal access to one's body or freedom of movement, and cannot be easily removed by the resident. ? Ensuring any ordered restraint is applied correctly. ? Not applying any type of restraint without a physician's orders [REDACTED]. ? Utilizing the proper restraint if ordered. ? Items that can be considered a restraint: sheet, leg restraints, arm restraints, hand mitts, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. All staff remaining to be in-serviced by the Administrator and assigned Silver Chair (online inservice program) courses will not be allowed to work until the in-service has been completed. 100% of all full-time employees will be in-serviced on Abuse/Neglect and restraints by 02/19/13. PRN staff will not be scheduled to work until in-service has been completed, any new employees will be in-serviced during orientation. After 02/28/13, no employee will be able to work until in-service has been completed. The silver chair courses are used to enhance the above in-services regarding abuse/neglect and restraints. Silver chair courses were assigned to all staff on 02/09/13 regarding prevention, identifying and reporting abuse/neglect, and creating a restraint free environment. Expected completion date of the Silver chair courses will be 02/28/13. Staff members will not be allowed to work without completion of their Silver chair course after 02/28/13. 1. 2. 3. 4. 100 % skin rounds were completed by DON, Compliance Nurse, ADON, and 2 nurses from a sister facility on 02/09/13. Skin rounds were completed to look for unknown bruising, skin tears or other signs of trauma. 5. Quality of life interview were conducted with all interviewable residents on 02/09/13 by the facility Social Worker (Quality of Life interviews encompass feelings of safety and wellbeing). 6. Staff interviewed regarding abuse, neglect and restraint policy by Administrator and Social Worker 020/9/13-02/14/13. Questions asked included: Who is the abuse prevention coordinator? Have you ever witnessed any resident restrained for staff convenience? Definition of all types of abuse. Purpose of the interview was to determine staff knowledge of abuse, if they could identify abuse, prevention of abuse and reporting abuse. 7. Complete personnel file audit was done to determine if all background checks and Nurse Aide Registry checks had been completed on 02/09/13 by Human Resource Director, all were current. Monitoring: 1. Q (every) 2 hr. monitoring initiated on all residents from 6 PM to 6 AM by the charge nurse on duty to ensure all residents are safe and cared for and that staff are neither abusing/neglecting the residents or restraining residents without a medical reason or physician's orders [REDACTED]. ? Resident bruising, skin tears ? Resident acting fearful of staff or crying ? Resident restrained improperly or any resident restrained by any device, i.e. belts, vest, sheets, etc. without a physician's order [REDACTED]. Monitoring other staff for potential burnout by observing for: exhaustion, lack of interest, decreased performance, negativity, anger, sadness, defensive. CNA ' s will continue to make rounds Q 2 hrs. and PRN to assist with ADL care. Charge Nurses w

Based on observation, interview and record review the facility failed to ensure the provision of adequate supervision, monitoring and functioning of a Wanderguard (bracelet alarm monitoring device) to prevent the elopement for one (1) of 7 sampled residents with exit seeking behaviors (Resident #1) and ensure that six (6) of 6 residents who were at risk for elopement and currently wearing Wanderguard assistive devices were monitored according to physician orders.(Residents #2, #3, #4, #5, #6 and #7) 1.) Resident #1, [AGE] year old male, with a history of exiting seeking behaviors (frequent threats of leaving, several attempts to purchase a vehicle and telling facility staff he was leaving to go to Idaho where his brother lives) eloped from the facility unnoticed on 4/15/11 at about 8:00 AM in his electric wheelchair, when his Wanderguard bracelet failed to alarm. Resident #1 was located by a Sheriff ' s Deputy, 7/10 of a mile from the facility at the intersection of Highway 16 and Barrow Street and returned to the facility 4/15/11 at 8:45 AM. Resident #1 had been attempting to hitchhike his way to a nearby town, 22 miles away to purchase a car. Ten days after the elopement, on 4/25/11, Resident #1 was discharged from the facility. 2.) Six (6) of 6 residents (Residents # 2,3,4,5,6 and 7) currently identified at risk for elopement, wore Wanderguard devices, and had physician orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 5/27/11 at 12:15 PM. While the IJ was lowered to a non-Immediate Jeopardy on 5/27/11 at 3:05 PM, the facility remained out of compliance at a potential for more than minimal harm at a pattern that is not an IJ because the facility administrative staff had not had time to ensure all staff had received training, all physician orders [REDACTED]. This deficient practice allowed Resident #1 to elope the facility unnoticed by staff, placing him at risk for serious harm, injury or even death with the potential to place the 6 additional residents wearing a Wanderguard at risk for serious harm. The findings include: 1. Review of the facility Incident Report, dated 4/15/11, for Resident #1 reflected at 8:30 AM the resident was returned to the facility by the County Sheriff's Department officer. Resident #1 was in his electric wheelchair on Highway 16 at Barrow Street going out of town. Resident #1 was wearing an electronic monitoring bracelet on his ankle. Review of the Incident Report Summary of Investigation reflected the following: Resident's personal alarm failed to sound alarm and he left the facility in electric wheel chair. Was seen by officer attempting to hitchhike in electric wheelchair approximately seven tenths of a mile from facility. Officers brought resident back to facility. Resident stated he was going to a nearby town to buy a car. Review of the facility investigation report dated 4/15/11 for Resident #1 reflected on 4/15/11 Resident #1 was returned to the facility by a Sheriff Department Deputy. Resident #1 was found on Highway 16 at Barrow Street in his electric wheelchair leaving town. The report reflected Resident #1 had an electronic monitoring bracelet on his ankle which did not lock the facility doors or sound the alarm. In an interview on 5/27/11 at 1:30 PM the County Sheriff's Deputy, who found and returned Resident #1 to the facility, stated he found Resident #1 going north on Highway 16 toward the next town. He further stated Resident #1 was moving down the shoulder of the highway in his electric wheelchair, holding his thumb out for a ride. He stated he did not know for sure but, " I speculated Resident #1 left the facility, traveled down Reynolds Street to Highway 16, turned left and continued to travel southwest on Highway 16 to Barrow Street, which is where he was located". Observations on 5/27/11 at 1:45 PM while traveling from the facility on Reynolds Street to Highway 16 there were five (5) street intersections to cross before coming to Highway 16. Turning right onto Highway 16 revealed a steep incline from Reynolds Street to Barrow Street. Highway 16 between Reynolds Street and Barrow Street was a 2 lane highway with a posted speed limit of 45 miles per hour. While traveling Highway 16 between Reynolds and Barrow Streets several semi-tractor trailer trucks passed going each way. The total distance by odometer reading from the facility to the intersection of Highway 16 and Barrow Street was 0.8 miles. Hazardous features noted were a railroad track five (5) blocks from the facility. A pond across Highway 16 at Barrow Street and heavy traffic on Highway 16 of cars, semi-trucks and numerous gravel trucks coming out of the gravel plant on Highway 16 across from Barrow Street. Review of the admission face sheet dated 10/28/10, for Resident #1 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the consolidated physician's orders [REDACTED]. Review of the nurses notes, dated 2/24/11 thru 4/15/11, for Resident #1 reflected the following: 3/6/11-8:15 PM- Resident told this LVN (Licensed Vocational Nurse) that he was leaving tomorrow. That he had a handicap van to be delivered tomorrow and he was going to Boise Idaho. 3/7/11-7:00 AM- Told this nurse that this was his last day here. States he was going to Waco. States resident was buying a handicap van to go to Idaho. 8:30 AM- Resident up in power wheelchair. using phone. States local car dealership not able to come pick him up. Looking for phone book to call another car dealership. 9:00 AM-Resident anxiously waiting for someone to take him to a nearby town. 9:50 AM-Received order for resident to have a 'Wanderguard' due to resident delusional episode and concern of resident ' s safety. 10:00 AM-Resident has stated he was going to leave nursing home and hitch hike to a nearby town. Review of the most current Elopement Risk Assessment/Care Plan, dated 3/7/11, for Resident #1 reflected a total score of 24. Further review of the form reflected the following: 'If the resident has a score of 10 or more, the resident is a risk for elopement'. Review of the consolidated physician orders [REDACTED]. Check placement and working properly every shift. Review of the Treatment Sheet, dated 4/11, for Resident #1 reflected the following: Check placement and working properly every shift documented as ordered. Review of the Resident Discharge Summary, dated 4/25/11, reflected Resident #1 was discharged in the care of his family to be admitted to a facility with a secure unit and closer to his family in another town. 2.) Residents #2 through #7: a.) Review of the admission face sheet, dated 10/28/10, for Resident #2 reflected an admission date of [DATE] and the following diagnoses; Diabetes, Benign Prostatic Hypertrophy, Undersocialized Conduct, Schizophrenia, Dementia and Psychosis Review of the Elopement Risk Assessment, dated 3/30/11, for Resident #2 reflected a score of 14. Review of the consolidated physician orders, dated 4/11 and 5/11, for Resident #2 reflected the following order dated 9/13/10: walk resident to door every day to confirm working. Review of the Treatment Sheets, dated 4/11 and 5/11, for Resident #2 reflected the following: Walk resident to door every day to confirm working. No documentation of this order was followed was found on the treatment sheet. b.) Review of the admission face sheet, dated 10/28/10, for Resident #3 reflected an admission date of [DATE] and the following diagnoses; Mental Retardation, Epilepsy, Depression, Explosive Personality Disorder and Hypertension. Review of the Elopement Risk Assessment, dated 5/11/11, for Resident #3 reflected a score of 21. Review of the consolidated physician orders, dated 5/11, for Resident #3 reflected the following order dated 9-13-10: Walk resident to door every day to confirm working. Review of the treatment sheets, dated 5/11, for Resident #3 reflected the following: Walk resident to door every day to confirm working not documented. c.) Review of the admission face sheet, dated 4/27/11, for Resident #4 reflected an admission date of [DATE] and the following diagnoses; Hypertension, Diabetes, Anxiety, Depression, Memory Loss and Dementia. Review of the Elopement Risk Assessment, dated 1/27/11, for Resident #4 reflected a score of 14. Review of the consolidated physician orders, dated 4/11 and 5/11, for Resident #4 reflected the following order dated 1/27/11: Walk resident to door every day to confirm working. Review of the Treatment Sheets, dated 4/11 and 5/11, for Resident #4 reflected the following: Walk resident to door every day to confirm working not documented d.) Review of the admission face sheet, dated 10/28/10, for Resident #5 reflected an admission date of [DATE] and the following diagnoses; Diabetes, Atrial Fibrillation, Chronic Ischemic Heart Disease, Hypertension, Dementia, Congestive Heart Failure, Alzheimer and Depression. Review of the Elopement Risk Assessment, dated 5/25/11, for Resident #5 reflected a score of 23. Review of the consolidated physician orders, dated 4/11 and 5/11, for Resident #5 reflected the following order dated 9/13/10: Walk resident to door every day to confirm working. Review of the Treatment Sheets, dated 4/11 and 5/11, for Resident #5 reflected the following: Walk resident to door every day to confirm working not documented e.) Review of the admission face sheet, dated 10/28/10, for Resident #6 reflected an admission date of [DATE] and the following diagnoses; Diabetes, Schizoaffective Disorder, Neoplasm (tumor) of Brain, Epilepsy, and Anxiety. Review of the Elopement Risk Assessment, dated 3/30/11, for Resident #6 reflected a score of 13. Review of the consolidated physician orders, dated 4/11 and 5/11, for Resident #6 reflected the following undated order: Walk resident to door every day to ensure Wanderguard is working properly. Review of the Treatment Sheets, dated 4/11 and 5/11, for Resident #6 reflected the following: No documentation of order was found on treatment sheets. Review of the care plan, dated 4/28/11, for Resident #6 reflected the following: Resident will wander: Check for placement every day. Walk resident to door every day to ensure wanderguard is working properly. f.) Review of the admission face sheet, 10/28/10, for Resident #7 reflected an admission date of [DATE] and the following diagnoses; Hypertension, Cardiovascular Disease, Depression and Dementia. Review of the Elopement Risk Assessment, dated 5/11/11, for Resident #7 reflected a score of 13. Review of the consolidated physician orders, dated 4/11 and 5/11, for Resident #7 reflected the following order dated 9/13/10: Walk resident to door every day to confirm working. Review of the Treatment Sheets, dated 4/11 and 5/11, for Resident #7 reflected the following: Walk resident to door every day to confirm working not documented In an interview on 5/27/11 at 10:30 AM LVN A stated, "Wanderguard bracelets are checked for placement every shift and checked for proper functioning every Friday morning". She further stated when checking functioning on Friday mornings the nurses either take the resident to the door to check functioning or use the testing device. LVN A stated "On the treatment sheet for Resident #1, she initialed everyday that she checked placement". She further stated she was not aware the physician orders [REDACTED]. In an interview on 5/27/11 at 10:40 AM LVN D stated she checks Wanderguard placement every shift to make sure it is still on the resident and tests the functionality on Friday morning. She further stated she was not aware the physician orders [REDACTED]. In an interview on 5/27/11 at 10:44 AM the Director of Nurses (DON) stated Wanderguard bracelets are checked for placement and function, by the nurses at least once a shift. The DON further stated the facility did not have a policy or procedure for the electronic monitoring bracelets. On 5/27/11 at 12:15 PM the facility's Director of Nurses and acting Assistant Administrator were informed that an Immediate Jeopardy existed. On 5/27/11 at 3:05 PM the facility provided the surveyor with a written plan of removal which reflected the following: Wanderguard system failure 1. All wander guards were immediately checked for placement and proper function. 2. Wander guards will be checked by nursing staff every shift for placement and function. This will be documented on the treatment sheet. 3. Maintenance supervisor/designee will check doors every day to ensure proper functioning. 4. All Nursing staff will be in serviced on wander guards system, prior to returning to work. 5. Physician orders [REDACTED]. 6. Elopement risk assessments will be updated on all residents utilizing a wonder guard today, on admission, quarterly and with a significant change. (sic) 7. A wander risk notebook was initiated. The book will contain a description of each resident utilizing a wander guard. 8. Findings of monitoring will be discussed during the morning meeting and during the monthly QA (Quality Assurance) meetings; any failure of the system will be corrected immediately. Observations on 5/27/11 between 2:00 PM and 5:00 PM revealed residents with Wanderguard bracelets being taken to the doors to check electronic monitoring functionality. Observation on 5/27/11 at 3:00 PM revealed the Maintenance Supervisor checking functionality of the electronic monitoring system. Observations on 5/27/11 between 2:00 PM and 5:00 PM revealed elopement risk assessments being conducted on residents with Wanderguard bracelets. Review of the physician orders [REDACTED]. In an interview on 5/27/11 at 4:00 PM LVN A stated she had attended training today on the electronic monitoring devices and would be checking functionality of the system every shift. In an interview on 5/27/11 at 4:10 PM LVN D stated she had attended training today on the electronic monitoring devices and would be checking functionality of the system every shift. In an interview on 7/27/11 at 4:20 PM LVN E stated she had attended training today on the electronic monitoring devices and would be checking functionality of the system every shift. On 5/27/11 at 5:15 PM the facility's DON and acting Assistant Administrator were informed the IJ had been lowered to more than minimal harm at a pattern that is not immediate jeopardy, because the facility had not yet in-serviced all of the staff, implemented and evaluated their corrective action. The DON provided the number (6) of residents in the facility with electronic monitoring bracelets.