Every finding on record at Mesa View Senior Living

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 4 kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated in House A kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the freezer in House A on 10/13/25 at 10:30 AM revealed the following:1. (1) pie shell, open to air, with no label or date, not in original box.2. (1) package of diced potatoes, not labeled and open to air. 3. (1) Ziplock baggie of frozen cookie dough, no label, not in original box. 4. (1) brown bag of unknown food item, open to air, not labeled, not in original box5. (1) brown bag of unknown food item, not labeled, not in original box 6. (1) Ziplock bag of onions, not labeled, not in original box.7. (1) Ziplock bag of pastry sheets, open to air, not labeled, not in original box8. (3) Ziplock bags of breadsticks, not labeled, not in original box, one of the bags was slimy and greasy to the touch9. (1) Ziplock bag of a meat product, frost in the bag covering all the food, no label, not in original package10. (1) large package of bacon, no label or date, not in original box.11. (1) Ziplock bags of cheese cubes, not labeled, not in original box, one bag was open to air. Observation of the freezer in House A on 10/13/25 at 2:00 pm revealed the following: 1. (1) pie shell, open to air, with no label or date, not in original box.2. (1) package of diced potatoes, not labeled and open to air. 3. (1) Ziplock baggie of frozen cookie dough, no label, not in original box. 4. (1) brown bag of unknown food item, open to air, not labeled, not in original box5. (1) brown bag of unknown food item, not labeled, not in original box 6. (1) Ziplock bag of onions, not labeled, not in original box.7. (1) Ziplock bag of pastry sheets, open to air, not labeled, not in original box8. (3) Ziplock bags of breadsticks, not labeled, not in original box, one of the bags was slimy and greasy to the touch9. (1) Ziplock bag of a possibly meat product, frost in the bag covering all the food, no label, not in original package10. (1) large package of bacon, no label or date, not in original box. 11. (2) Ziplock bags of cheese cubes, not labeled, not in original box, one bag was open to air.12. (1) large Ziplock bag of turkey or chicken strips, open to air, no label not in original box. In an interview on 10/13/25 at 2:15 pm, [NAME] F stated all foods in the freezer should be labeled and dated. She stated she did not know what the unlabeled foods in the brown bags and the Ziplock bag of meat with frost were. She stated she had been trained by the DM from the hospital on how to label and date foods.She stated she did not know why the foods had been open to air and not labeled. She stated the food issues could cause food borne illnesses in the residents. In an interview on 08/21/23 at 2:30 pm with the DM, she stated she had been supervising all the kitchens in the facility. She stated the expectation was all foods needed to be dated with the receiving date. She stated each cook in each house had been responsible for dating the food. She stated all foods should be closed to air. When asked about labeling the foods she stated the cooks do not have to label the food because they know what it is. She stated the brown bags of food and meats, should be labeled as you cannot tell what had been in the brown bag and you might not be able to tell what kind of meat may have been in the package. She stated all other food items did not have to be labeled with a name. She stated the food had been kept in the original boxes it was packed in and the box had a name on the box. She stated she had trained the staff in their job duties and had held in-services as needed. She stated she spot- checked the kitchens when she had been in the facility. The DM stated the consequences of unlabeled, undated food would be food borne illness. The DM stated they follow the TFER (Texas Food Establishment Rules) in the kitchen.Record review of the undated facility policy titled Sanitary Food Handling, revealed the facility will prepare store and serve food under sanitary conditions using the most recent version of the Texas Food Establishment Rules and the Texas State Department of State Health Food Services food sanitation requirements as a guide.They will meet the standards imposed by local, state and federal codes regarding food and food handling.Record review of the facility provided policy titled Serve Safe Essentials, page 7-4, documented if you take food out of its original package, put it in a clean sanitized container and cover it. The new container must be labeled with the name of the food being stored and its original use by or expiration date.Record review of the facility provided untitled, undated policy, stated food labels should include the common name or a food statement that clearly and accurately identifies the food. If the food is unlabeled, then dispose in trash due to unknown age. Record review of the 2021 US Food Code revealed the following: 3-302.12 Food Storage Containers, Identified with Common Name of Food.Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, shall be identified with the common name of the FOOD. Record review of the 2015 TFER (Texas Food Establishment Rules) revealed: S228.79. Labeling. (a) Food labels. (1) Food packaged in a food establishment, shall be labeled as specified in law, including 21 CFR 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381, Subpart N, Labeling and Containers. Pf [24] (2) Label information shall include: (A) the common name of the food, or absent a common name, an adequately descriptive identity statement. (b) Food storage containers, identified with common name of food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, shall be identified with the common name of the food.

Based on observation, interview, and record review, the facility failed to ensure residents or their representative had properly completed Out-of-Hospital Do-Not-Resuscitate(OOH-DNR) form which requires the document to be properly completed and signed, including the notary's date of completion for 4 (Residents #2, # 4, #8, and #11) of 17 residents reviewed for advanced directives.Residents #2, # 4, #8, and #11's DNR form in their record was missing the date of when the notary signed the form.This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representatives expressed wishes.Findings included:Resident #2Record review of Resident #2's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to included but not limited to epilepsy (seizure disorder), unspecified, chronic kidney disease (loss of kidney function) and essential hypertension (high blood pressure). Resident #2 was listed in Advance Directives as being a DNR. Record review of Resident #2's quarterly MDS was completed [DATE] listing her with a BIMS of 10 indicating her cognition was moderately impaired, and she had a functionality of being dependent with most of her ADL's Record review of Resident #2's care plan last revision dated [DATE] revealed the following: Focus:Resident #2 has the right to choose Advance Directives that reflect her personal values and beliefs with interventions for her preferences to be honored.Record review of the clinical record for Resident #2 revealed an Order Summary with Active Orders as of [DATE] with the following order: -DNR-Active [DATE] Record review of the clinical record for Resident #2 revealed a DNR dated [DATE] (signed by the physician) revealed with the following:Section - Two Witnesses - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form. Resident #4Record review of Resident #4's face sheet revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to included but not limited to heart failure, paroxysmal atrial fibrillation (irregular heartbeat), chronic combined systolic and diastolic heart failure (heart not pumping strong), chronic obstructive pulmonary disease (progressive lung condition that makes it difficult to breathe). Resident #4 was listed in Advance Directives as being a DNR. Record review of Resident #4's quarterly MDS was completed [DATE] listing her with a BIMS of 03 indicating her cognition was severely impaired, and she had a functionality of being dependent with most of her ADL's Record review of Resident #4's care plan and last revision dated [DATE] revealed the following: Focus:Resident #4 has the right to choose Advance Directives that reflect her personal values and beliefs with interventions for her preferences to be honored. Record review of the clinical record for Resident #4 revealed an Order Summary with Active Orders as of [DATE] with the following order: -DNR-Active [DATE] Record review of the clinical record for Resident #4 revealed a DNR dated [DATE] (signed by the physician) revealed with the following:Section - Two Witnesses - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.Resident #8Record review of Resident #8's face sheet revealed he was a 74 -year-old male resident admitted to the facility on [DATE] with diagnoses to included but not limited to Heart failure, essential hypertension and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. Resident #8 was listed in Advance Directives as being a DNR. Record review of Resident #8's quarterly MDS was completed [DATE] listing him with a BIMS of 08 indicating his cognition was severely impaired, and he had a functionality of set up/clean up assistance with eating, toileting, supper and lower body dressing.Record review of Resident #8's care plan last revision dated [DATE] revealed the following: Focus:Resident #8 has the right to choose Advance Directives that reflect his personal values and beliefs with interventions for her preferences to be honored. Record review of the clinical record for Resident #8 revealed an Order Summary with Active Orders as of [DATE] with the following order: -DNR-Active [DATE]Record review of the clinical record for Resident #8 revealed a DNR dated [DATE](signed by the physician) revealed with the following:Section - Two Witnesses - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.Resident #11Record review of Resident #11's face sheet revealed she was an 83 -year-old female resident admitted to the facility on [DATE] with diagnoses to included but not limited to Parkinson's Disease with dyskinesia (erratic movement), essential hypertension (high blood pressure) and personal history of other circulatory system. Resident #11 was listed in Advance Directives as being a DNR. Record review of Resident #11's admission MDS was completed [DATE] listing her with a BIMS of 15 indicating her cognition was intact, and she had a functionality of independence in eating, toileting, upper and lower body dressing.Record review of Resident 11's care plan last revision dated [DATE] revealed the following: Focus:Resident #11 has the right to choose Advance Directives that reflect her personal values and beliefs with interventions for her preferences to be honored. Record review of the clinical record for Resident #11 revealed an Order Summary with Active Orders as of [DATE] with the following order: -DNR-Active [DATE] Record review of the clinical record for Resident 11 revealed a DNR dated [DATE](signed by the physician) revealed with the following:Section - Two Witnesses-- there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.During an observation and interview on [DATE] at 2:10 PM LVN E who worked in House A and B where #2, # 8 and #11 resided. She stated if a DNR was not completely correct or accurately the staff would be required to provide CPR. LVN E reviewed Resident #8's DNR who resided in House A and stated she did not observe anything incorrect with the form and would honor the DNR as written.During an observation and interview on [DATE] at 2:47 PM the ADM stated that a DNR that was not completed correctly could not be honored. The ADM pulled up Resident #8's DNR and said she was not sure if it was correct or not. The ADM said that the administrative personnel were responsible for ensuring DNRs was completed correctly and a possible negative outcome for not having a completed DNR in the file would be that a resident would not have their wishes followed.During an interview on [DATE] at 9:24 AM, the DON stated she was aware that some DNR forms were incomplete and would not be valid because the notary did not sign the form at the time the signatures were witnessed. The DON stated the facility uses various notaries from the community and believed the notary may have missed dating the form. The DON further stated that a possible negative outcome of not having a properly completed DNR would be a resident's wishes might not be honored.During an interview on [DATE] at 9:45 AM, LVN D, who worked in House C where #4 Resident resided stated if a DNR form was not completed correctly with accurate dates and signatures, the DNR would be invalid. She stated that in such a case, staff would be required to initiate CPR, which would go against the resident's expressed wishes. LVN D stated she believed it was the social worker's responsibility to ensure DNR forms were completed accurately and in accordance with requirements.During an interview on [DATE] at 9:54 AM, the SW stated that many residents were admitted to the facility with their DNR forms already completed. The SW stated that the facility uses various notaries from the community, or the resident or resident's Power of attorney may obtain a notary from outside the facility. The SW stated she was responsible for reviewing and verifying that DNR forms were completed accurately. She further stated that if a DNR form was not completed correctly, the resident's wishes might not be followed.Record review of Advanced Directives (no date) did not have any information regarding OOH-DNRs.Record review of the undated OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES form that was in the admission Packet 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 observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and #32) of 17 Residents reviewed for comprehensive care plans. -The facility failed to address the use of oxygen in Resident #4 and Resident #32's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: Resident #4: Record review of Resident #4's face sheet dated 10/13/2025 revealed an [AGE] year-old female resident admitted to the facility originally on 1/27/2025 and readmitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). Record review of Resident #4's quarterly MDS completed 8/05/25 listed her with a BIMS of 03 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Resident #4 was listed as on oxygen therapy while a resident. Record review of Resident #4's order summary reports revealed the following:- O2 at 2-5 liters PRN for shortness of breath. - Verbal Active 01/27/2025. Record review of Resident #4's care plan with date of initiation 1/27/2025 revealed no care plan for oxygen use. During an observation on 10/13/2025 at 10:22 AM Resident #4 was in bed sleeping with her oxygen tubing rolled up next to her head. Resident #4's oxygen concentrator was on. Resident #4 awoke to knocking. Resident #4 was confused and did not respond appropriately to questions. Resident #4 did appear in good condition. Resident #32: Record review of Resident #32's face sheet dated 10/13/2025 revealed an [AGE] year-old female resident admitted to the facility originally on 3/06/2019 and readmitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), Bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), left ventricular failure (a condition where the left side of the heart's main pumping chamber, the left ventricle, cannot pump enough oxygenated blood to the body), and rheumatoid arthritis (autoimmune inflammation of the joints). Record review of Resident #32's quarterly MDS completed 7/15/25 listed her with a BIMS of 99 indicating she was unable to complete the interview due to memory problems, and she had a functionality of being dependent on staff for most of her activities of daily living. Resident #32 was listed as on oxygen therapy while a resident. Record review of Resident #32's order summary reports revealed the following:- O2 at 2-5 liters QHS for shortness of breath at bedtime related to HEART FAILURE, UNSPECIFIED (I50.9) - Verbal Active 12/20/2021 Record review of Resident #32's care plan with date of initiation 10/06/2020 and last revision date of 4/27/2025 revealed no care plan for oxygen use. During an observation on 10/13/2025 at 10:32 AM Resident #32 was in bed awake but unable to respond effectively to any questions. Resident #32 was wearing O2 via a NC. Resident #32 appeared in good condition. During an observation on 10/14/2025 at 8:18 AM Resident #32 was in bed sleeping peacefully with her oxygen on via NC. During an interview on 10/14/2025 at 3:11 PM MDS C confirmed she was responsible for completing all care plans for residents. MDS C reviewed Resident #32 chart, verified Resident #32 had orders for oxygen, had a diagnosis of sarcoidosis (a chronic inflammatory disease characterized by the formation of non-caseating granulomas in various organs, most commonly in the lungs) which would require oxygen, and that Resident #32 had orders for oxygen at 2-5L/min via NC at HS and PRN for SOB. MDS C verified that Resident #32 did not have oxygen use addressed in her care plans and has not had it addressed for a while. MDS C reported I just missed it. I am not sure what happened. MDS C reported that oxygen should be care planned, especially if it has orders. MDS C reported that not addressing a resident's needs in their care plans such as oxygen use could be detrimental to their health. It could result in impaired oxygen exchange and affect that resident's condition. MDS C was unavailable for comment on 10/15/2025 when Resident #4 was discovered to have no care plans for her oxygen therapy. During an interview on 10/15/2025 at 8:55 AM the DON reported we really don't know why the oxygen was missing on the care plans. When asked if the care plan not addressing the residents need for oxygen was an issue the DON reported, I don't know. The order was in the chart so the residents need for oxygen was addressed. No further comment was given. Record review of the facility provided policy titled Care Plans reviewed annually, revealed the following: Baseline:3. The care plan will include at the minimum the following information:b. Physician orders. Comprehensive:Policy Statement - An individualize comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The House B medication cart had an inulin bottle that expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings included: During an observation on [DATE] at 11:27 AM the House B medication cart revealed 1 [NAME] insulin marked with opened/access date of [DATE] (35 days from [DATE]). RN A reported the insulin pen marked opened/access [DATE] expired, that an insulin should be discarded 28 days after it was opened/accessed, and that the resident involved receives a scheduled dose every evening. RN A immediately discarded the insulin pen and opened a new one. RN A marked the new insulin pen with the opened/accessed date. RN A reported that using an expired medication such as this insulin on a resident could result in the medication losing its effectiveness and could affect the residents hyper or hypoglycemic (high/low blood sugar) reactions. During an interview on [DATE] at 8:48 AM the DON reported that all insulins should be labeled with required information such as the resident's name and dose. The DON reported that a multidose vial should be labeled when pulled out of the box for the first time. When asked what information the insulin should be labeled with the DON stated, the residents name and such. When asked what information staff should put on the label when an insulin was opened/accessed and the DON stated, I am not sure what you are asking. When asked if an insulin could be used for 60 days after it was opened the DON stated, Yes. During an interview on [DATE] at 9:22 AM the DON reported that administering an insulin that expired could result in the resident not receiving the appropriate dose of medication. Record review of the facility provided Insulin Administration reviewed annually, revealed the following: Purpose: To provide guidelines for the safe administration of insulin to resident with diabetes.Insulin Delivery.Procedure:4. Check expiration date, if drawing from an open multidose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). Record review of manufacturer recommendation for Lantus Insulin at lantus.com revealed the following instructions:- How to store your opened Lantus Solostar Pen:After 28 days, throw your opened Lantus pen away-even if it still had insulin in it.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #32) of 17 residents reviewed for respiratory care. -Resident #32 was not receiving oxygen at the correct dose. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings included: Record review of Resident #32's face sheet dated 10/13/2025 revealed an [AGE] year-old female resident admitted to the facility originally on 3/06/2019 and readmitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), Bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), left ventricular failure (a condition where the left side of the heart's main pumping chamber, the left ventricle, cannot pump enough oxygenated blood to the body), and rheumatoid arthritis (autoimmune inflammation of the joints). Record review of Resident #32's quarterly MDS completed 7/15/25 listed her with a BIMS of 99 indicating she was unable to complete the interview due to memory problems, and she had a functionality of being dependent on staff for most of her activities of daily living. Resident #32 was listed as on oxygen therapy while a resident. Record review of Resident #32's order summary reports revealed the following:- O2 at 2-5 liters QHS for shortness of breath as needed - Verbal Active 12/20/2021. - O2 at 2-5 liters QHS for shortness of breath at bedtime related to HEART FAILURE, UNSPECIFIED (I50.9) - Verbal Active 12/20/2021. Record review of Resident #32's care plan with date of initiation 10/06/2020 and last revision date of 4/27/2025 revealed no care plan for oxygen use. During an observation on 10/13/2025 at 10:32 AM Resident #32 was in bed awake but unable to respond effectively to any questions. Resident #32 was wearing O2 via NC at 0.5L/min. Resident #32 appeared in good condition. During an observation on 10/14/2025 at 8:18 AM Resident #32 was in bed sleeping peacefully her oxygen on at 0.5L/min via NC. During an interview on 10/14/2025 at 9:22 AM MA B (the skilled staff member responsible for Resident #32 this shift) checked Resident #32's oxygen and verified that the current dose Resident #32 was receiving 0.5L/min via her NC. MA B then checked Resident #32's orders and noted Resident #32 ordered for 2-5L/min via NC prn and at HS. MA B reported, her dose is not correct. We need to up her dose. MA B reported that a resident not receiving enough oxygen could have increased SOB, they would not get enough oxygen, and that could increase their confusion. MA B reported that when a resident was not getting enough oxygen then the first sign could be increased confusion. MA B checked Resident #32's O2 saturation with a level of 95% noted. MA B reported that the nurses were responsible for making sure the oxygen was set at the right level. Ma B reported that the nurse responsible for this unit left this shift to take care of a sick family member and she (MA B) was her replacement. During an interview on 10/15/2025 at 8:51 AM the DON reported that staff were not following the physicians' order when they administered Resident #32s oxygen at 0.5L/min and that the nurses or the medications aide's responsibility to check the oxygen to ensure the correct dose was administered. The DON reported that not administering oxygen per the physicians' orders at the correct dose could result in impaired oxygen exchange for the resident. Record review of the facility provided policy titled, Oxygen Policy undated, revealed the following: Policy:.appropriately, trained staff may assist the resident with oxygen administration per physicians' orders. 1) Any resident using oxygen must have a current physician order.Oxygen Orders and Administration:1) Oxygen administration per the residents' physicians' orders.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all foods served to residents were labeled and dated as to when they were received and/or opened. The facility failed to ensure food packaging was properly closed and not open to air. This failure could place residents at risk of food-borne illness. Findings included: An initial tour of the kitchen was conducted on [DATE] at 10:22AM and the following was noted: (1) 4-pound bag dry of cheesecake filling mix-no date received. (1) 10-pound bag of tri-colored rotini-no date received. (1) partial 2-gallon zip closure bag of spaghetti noodles-no date received. (1) partial 10-pound box of cracker crumbs-no date received. (1) 36-ounce box of wild rice blend-no date received. (13) individual packages of Oreo cookies-no date received. (2) 2-pound and (1) partial 2-pound bags of fresh grapes-no date received, and no date opened. (1) whole Smokehouse Pit ham-no date received. (1) 5-oound bag of shredded cheddar cheese-no date received, and no date opened. (22) individual cups of fat free chocolate ice cream-no date received. (1) partial 10-pound bag of frozen pancakes-no date received and open to air. (1) partial 5-pound box of frozen tart pastry shells-no date received and open to air. (1) quart and (1) partial quart of heavy whipping cream-no date received, and no date opened. (1) 8-ounce container of whipped topping-no date received. (1) 16-ounce bottle of lite Italian salad dressing-no date received. (1) 9-ounce package of turkey lunch meat-no date received. (1) partial 5-ounce bag of pepperoni-no date received, and no date opened. (2) 46-ounce cans of pineapple juice-no date received. (3) 50-ounce pump containers of Coffee Mate creamer-no date received, and no date opened. Instructions on containers to discard after 30-days. An interview with the Dietary Manager on [DATE] at 1:38PM revealed the negative outcome of serving foods which had not been dated or were open to air was residents could become sick if they consumed expired foods and foods could lose their nutritional value if left open to air. An interview with the Administrator on [DATE] at 11:50AM revealed the facility had no policy and procedures for food handling and food safety other than the Texas Food Establishment Rules (TFER).

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 120 days (8/24/24) of RN schedules reviewed for RN nurse coverage. The facility failed to ensure there were at least 8 hours of RN coverage on August 24, 2024. This failure could place residents at risk of receiving improper care in the event of an emergency and a diminished quality of life. Findings include: A record review of RN coverage for August, September, October, and November 2024, indicated on 8/24/24 there was no RN in the facility for a 24-hour period. An interview with the DON and ADM on 12/11/2024 at 11:50 AM, revealed there had not been an RN in the building on August 24, 2024. The ADM stated the facility did not have policy and procedures in place regarding RN coverage, other than the state and federal regulations. The DON stated the negative outcome of not having an RN in the facility for at least 8 consecutive hours, 7 days a week was residents who needed advanced care beyond the scope of an LVN, would not be cared for in a proper manner. In the event of an emergency, the LVN might not be equipped to handle resident needs and residents could have a decreased quality of life, due to their needs being outside the scope of practice for an LVN.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 3 (Sunset House ) medication carts observed for . The facility failed to dispose of Bisacodyl Suppositories that expired on 11-2024 in the medication cart located at the Sunset House. This failure could place residents receiving medications at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or receiving expired medications. Findings included: During an observation and interview on 12-11-2024 at 7:09 AM, of the Sunset House medication cart with LVN A, observation of middle drawer holding Bisacodyl Suppositories 10mg, expiration date 11/2024. LVN A stated she must have missed taking out the medication. LVN A took the medication out of the cart to be destroyed. During an interview on 12-11-2024 at 10:13 AM, LVN A stated that she was responsible for ensuring medication were checked and expired medications were taken out of the medication cart. LVN A stated that a possible negative outcome for having expired medications in the medication cart could cause negative symptoms for a resident. During an interview on 12-11-2024 at 10:39 AM, LVN B stated that all nurses were responsible for ensuring expired medications were disposed of and taken out of the medication cart. LVN B stated that expired medications were not effective, and it could possibly hurt the resident. During an interview on 12-11-2024 at 11:00 AM, MA C stated that all nurses were responsible for ensuring expired medications were disposed of and taken out of the medication cart. MA C stated that a possible negative outcome for giving a resident expired medication could be the medication would not be effective . During record review of facility's policy, 'Storage of Medications' (no date) revealed in part, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintain medication storage and preparation areas in a a clean, safe, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Resident #1) reviewed for medication administration, in that: CMA B administered medications to Resident #1 via crushed medications in yogurt with whipped cream and left Resident #1 unattended with the yogurt/medication mix. This was stated by CMA B during conversation with Investigator on 7/8/24 at facility and a written statement by CMA B. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization . Findings include: Interview with Administrator on 7/8/24 indicated that CMA B wrote a statement about crushing Resident#1's medications and putting them in yogurt with whipped cream, feeding Resident a few bites, and then leaving Resident#1 with yogurt/medication mix alone while CMA B went to help other residents for about one hour. Record Review of Resident #1 face sheet revealed. A [AGE] year-old female who was admitted to the facility on [DATE], with the following diagnoses: Alzheimer's Disease, Unspecified, Major Depressive Disorder Single Episode, Unspecified, Essential (Primary) Hypertension, Unspecified atrial Fibrillation Pain in Unspecified Joint. Needs assistance with personal care. Record Review of Resident #1's MDS dated [DATE]. Revealed a BIMS of 00 which indicates Cognitively Significantly Impaired and needs supervision. Record Review of Resident #1's care plan, revision on 04/09/24 revealed 'Administer medications as ordered. Monitor/document for side effects and effectiveness.' Record Review of Resident #1's active physician's orders printed 07/09/2024 revealed the following orders: *May Crush All Crushable Meds every day and night shift *Seroquel 50mg 1 tablet by mouth one time a day for Alzheimer's and Depressive Disorder *Tramadol 50mg 1 tablet by mouth four times daily for moderate to severe pain *Ativan 0.5mg 1 tablet two times a day for Alzheimer's and Depressive Disorder *Lisinopril 40mg 1 tablet twice daily for hypertension. During an observation and interview on 07/08/2024 at 10:18AM Resident #1 was sitting at breakfast table eating with her fingers. Sitting in wheelchair well-groomed and dressed nicely. Smiled when spoken to. Had no recollection of past actions when asked about getting out of bed that morning. Had no recollection of taking medications in yogurt. Was not oriented to time, date, or location. She stated she is happy and liked the people she is with. During an interview on 07/08/2024 at 9:29AM, CMA B stated on 6/22/24 she crushed Resident #1's medication and put it on top of yogurt with whip cream on top of the meds and yogurt to get Resident#1 to take her medications. She stated Resident#1 was the only one at the breakfast table at that time. She waited for Resident #1 to eat the yogurt. Resident #1 took about 3 bites of the yogurt and then she put it down and started eating her breakfast. CMA B left Resident #1 at the table with her uneaten medicated yogurt to help some other residents. During an interview on 07/08/2024 at 2:23PM LVN D stated she did not see any of what transpired with Resident #1s yogurt with crushed medications. CMA B called LVN D who was working in another house and told LVN D that she had left Resident #1 alone with the crushed medication in yogurt mixture. Resident #1 was monitored and showed no adverse physical symptoms. Record Review of in-service performed dated 07/08/2024 revealed that CMA B was reeducated on these topics: 'The 5 Rights of Medication Administration, Care of Residents with Dementia, and Medication Administration.' Record Review of facility provided policy titled, 'Medication Administration' reviewed annually states: 'Medications shall be administered Safely and timely, as Prescribed' and '24. Residents may self-administer their own medications only if the Attending Physician in conjunction with the Interdisciplinary Care Planning Team has Determined that they have the decision-making capacity to do it safely.'

Based on observation, interviews and record review, the facility failed to establish and maintain an infection 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 of 2 households (Bldg A and Building E) observed for sanitation and COVID protocols in that: Bldg A and Bldg E did not follow infection control policies related to sanitation and COVID- 19 transmission-based precautions for households and residents that were COVID- 19 positive. This failure could place residents at risk for infections, contamination, physical decline, and hospitalization . Findings included: An observation on 12/5/23 at 10:55 AM revealed no signs for donning and doffing PPE or transmission-based precautions on door. No PPE supplies were observed outside of Resident #1's room. An observation on 12/5/23 at 11:00 AM revealed CNA B in the dining room with 4 residents. CNA B sanitized hands, moved Resident's chair to another area of the table, walk into the kitchen and obtained two cups out of the cabinet. CNA B did not hand wash or use ABHR before obtaining the cups. An observation on 12/5/23 at 11:11 AM revealed DC C take off glove on right hand, climb on step ladder, obtain a clear bag with ungloved hand, step down, obtained a pan from a lower cabinet with gloved hand, place it on the countertop, and place clear bag in the pan with both gloved and ungloved hand. No changing of gloves or hand hygiene was practiced. At 11:13 AM, DC C continued to wear one glove on left hand, pressed on clear liner with brown substance in bag with both gloved and ungloved hand. DC C picked up a spoon with ungloved left hand, removed lid of pan with gloved hand, placed gloved hand on handle of pot and began stirring substance in the pan with the spoon in ungloved hand. DC C reached into a cabinet on the right side of the stove, removed a cloth with ungloved hand while gloved hand was on the cabinet handle and began cleaning the stove and countertop area. No hand hygiene or changing of gloves performed. DC C stepped to unviewable area of the kitchen with one gloved hand and one ungloved. An observation on 12/5/23 at 12:02 PM revealed Resident #2, Resident #3, Resident #4, and Resident #5 with no signs for donning and doffing PPE or transmission-based precautions on door. No PPE supplies were located outside of each resident's room. An interview on 12/5/23 at 10:23 AM, ADM stated that COVID policies have changed with the CDC. ADM stated she believed them to be five days and no symptoms for 24 hours before resident could leave isolation and CDC was quoting 10 days. ADM stated that DON reported to her that one resident came off of COVID-19 precautions while the others who tested positive for COVID-19 remained on precautions. An interview on 12/5/23 at 10:43 AM, AD stated that Resident #4 was off COVID-19 precautions while Resident #5 continued COVID-19 precautions. An interview on 12/5/23 at 11:23 AM, CNA D stated she received training on Infection Control within one-two months. CNA D stated that two residents in Bldg E tested positive . ADON and ICP were in charge of the trainings staff received. CNA D stated hand washing or ABHR were required if passing through the door into the kitchen. CNA D stated a negative outcome of not practicing hand hygiene can be contamination. An interview on 12/5/23 at 11:28 AM, CNA B stated hand sanitation was to be completed when entering the kitchen and wearing a mask if experiencing symptoms per the facilities policy of infection control. CNA B stated they must practice ABHR prior to touching anything for a resident. CNA B indicated staff receives training two to three times a year from ICP. State Surveyor asked CNA B about observation of not practicing hand hygiene before entering the kitchen area. CNA B confirmed did not practice hand hygiene before entering kitchen area. CNA B stated a negative outcome of not properly sanitizing hands could be contamination if resident's equipment was touched. An interview on 12/5/23 at 12:05 PM, HK F revealed rooms of Resident #2, Resident #3, and Resident #5 have COVID . HK F stated they were to wear mask in rooms of residents that were sick. When asked for a negative outcome, HK F stated there were no residents sick at this time so no masks were required. An interview on 12/5/23 at 12:11 AM, MA G stated isolation for COVID positive patients was five days with no fever. MA G stated they encouraged residents who left their rooms to wear masks. MA G indicated that training on COVID was on 11/27/23. MA G stated a negative outcome of not practicing infection control policies was infection can spread like wildfire. An interview on 12/5/23 at 1:24 PM with DC C revealed there was sanitizer for disinfecting and antibacterial soap to wash hands. DC C stated that both hands were to be gloved and if touching anything outside of food, must change gloves. DC C indicated training was the last week of October. DC C stated a negative outcome was contamination and can be complaints. State Surveyor recapped observation of donning only one glove to DC C and DC C denied only wearing one glove. DC C stated she always puts on two gloves. An interview on 12/5/23 at 3:55 PM, ADON and DON stated residents were to be quarantined for 10 days and staff was to test if they were symptomatic. If staff tests positive, they must be free of fever for 24 hours. If the staff does not experience symptoms, staff must wear a N95 mask and work with positive residents only. The ADON stated that precautions must be in place for all ten days for residents who test positive for COVID-19. State Surveyor inquired if staff was told a quarantine period of 5 days and DON stated CNAs and MAs went to a training on 12/2/23 where they were trained on a 5-day period for isolation. State Surveyor asked if staff were to follow facility guidelines or training. DON stated they were advised to follow facility guidelines. DON indicated that staff would need remediation if not followed. ADON provided the following dates resident's precautions were to be lifted: Resident #1 on 12/8/23, Resident #3 on 12/9/23, Resident #4 on 12/6/23, Resident #6 was unknown, Resident #5 on 12/5/23, Resident #2 on 12/6/23, Resident #7 on 12/5/23. Surveyor provided observation that one resident, Resident #4, continued protocol for COVID-19 infection and other residents did not have precautions in place. ADON stated a negative outcome could be the spread of COVID and DON stated a negative outcome could be the spread of infection. On 12/5/23 at 4:08 PM, State Surveyor attempted interview with ICP. Unable to contact. An interview on 12/5/23 at 4:50 PM, CNA I stated that working with COVID positive residents required gowns, gloves, and masks. CNA I indicated that precautions in place were signs on the door and PPE outside the resident's rooms. CNA I stated that the signs were proper protocol on donning and doffing PPE. CNA I indicated a negative outcome could be death. An interview on 12/5/23 at 4:50 PM, ADM revealed that MAs received a training on 12/2/23 regarding a new policy for COVID precautions. The ADM stated that MAs were trained the new policy was five days if no symptoms appeared and person was 24 hours without fever. Surveyor asked to obtain policy MA's were trained on. ADM unable to produce it as it came from an accredited school. ADM stated she would obtain it and provide a copy to State Surveyor. No copy of new protocols was received. Record review of in-service training on Infection Control, dated 9/27/23, showed CNA B, DC C, CNA H, and CNA I completed in-service. In-service provided Hand-washing Policy, not dated, and educated staff that all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing nose, before handling food, and when hands become obviously soiled. Record review of in-service training on Infection Control, dated 10/25/23, showed CNA B, DC C, CNA H, and CNA I completed in-service. Record review of in-service training, dated 11/29/23, revealed CDC protocol residents can be removed from Transmission based precautions 10 days after onset of symptoms and review of Infection Control assessment. ADM provided list of Microsoft Teams attendance of staff and stated not an accurate account of individuals who attended. Record review of Infection Control Program, not dated, stated under heading Policy-Line 4-Implement hand hygiene (handwashing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Under heading Procedure- 4. The facility will prohibit staff with a communicable disease/infection . from direct contacts with residents or their food-bullet point C- Staff that are symptomatic of influenza-like-illness are not to provide direct resident care for seven days after symptom onset or until 24 hours after resolution of symptoms, whichever is longer. 5. The facility will require staff to perform hand hygiene as indicated by national guidelines.

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 safety for 2 of 4 kitchens observed. Staff members failed to practice hand hygiene between plates during lunch service and wear hairnets while in the kitchen. This failure can place residents at risk for infection and cross contamination. Findings included: The following actions were observed in Bldg H: Observation on 11/14/23 at 12:03 PM: CNA D who completed hand hygiene touched scrubs, hair, and face, then delivered plates to residents in the dining room. Observation on 11/14/23 at 12:08 PM DON and CNA D delivered plates with no ABHR or hand washing. Observation on 11/14/23 at 12:09 PM DON delivered another plate, no ABHR; CNA D touched resident chair and clothing. Did not use ABHR prior to delivering food. LVN C touched chair and delivered plate without using ABHR. Observation on 11/14/23 at 12:09 PM CNA D delivered plate to resident. CNA D touching glasses and face then delivered food to resident without practicing ABHR. Observation on 11/14/23 at 12:13 PM CNA D did not use ABHR and delivered food to resident. LVN C touched plate of other resident with chair; delivered to food to resident. No hand hygiene practiced. Observation on 11/14/23 at 12:14 PM CNA D grabbed chair, no ABHR and proceeded to help resident with lunch. Observation on 11/14/23 at 12:15 PM: LVN C grabbed chair from the other dining room then delivered plate to resident. LVN C touched clothing and chair then assisted with meal. No hand hygiene practiced Observation on 11/14/23 at 12:19 PM revealed no hand sanitizer located in either dining room. Observed on 11/15/23 at 10:29 AM, CNA F an individual walk out of the kitchen with no hair net in place. An interview on 11/15/23 at 11:37 AM with DM indicated staff CNA F brought chili to the facility but did not enter kitchen. Observation on 11/15/23 at 3:37 PM, ADM picked up test tray from common room and delivered it to the kitchen. ADM was not wearing a hair net. Observation on 11/16/23 at 1:28 PM, CNA F entered the kitchen area of Bldg H without a hairnet. An interview on 11/16/23 at 1:31 PM with LVN C revealed that hand hygiene should be done between each plate. LVN C indicated staff receives training on it once a year. LVN C stated a negative outcome is things can transfer from resident to resident. An interview on 11/16/23 at 1:34 PM with CNA F revealed that she should wear a hairnet in the kitchen. CNA F was unable to say when her last training was. CNA G stated that Admin or dietary oversees training. CNA F stated a negative outcome could be it would have her hair or germs on the food. An interview on 11/16/23 at 1:39 PM with CNA J revealed the needs to use ABHR between every plate. CNA J indicated she did not receive training at the facility but when she worked at the hospital as a cook. Stated a negative outcome could be contamination. Record review of Employee Sanitary Practices, dated 2013, states the policy is for all kitchen employees with practice standard sanitary procedures. Record review of policy Food Safety and Sanitation, dated 2013, states: 2. b. All staff are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. o Hair restraints are required and should cover all the hair on the head. Record review of policy titled Hand Hygiene, not dated, states: 2. Alcohol based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water are not indicated per #1 above). According to the World Health Organization, hand hygiene is to be performed: o A- Prior to caring for a resident. o E- after contact with the resident environment. 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: o D- Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for 9 of 12 anonymous residents reviewed for resident rights. The facility did not make prompt efforts to follow through on grievances made for staff being on the phone or proper food temperatures when served. This failure could place residents at risk of weight loss, emotional distress, and decreased quality of life. Findings Included: An observation on 11/14/23 at 10:50 AM showed Cook D observed in Bldg E talking to someone on the phone via a pink headset that staff was wearing on head. Residents were present after a Resident Council meeting ended in the dining room. An observation on 11/14/23 at 10:55 AM showed Cook D returned to kitchen in Bldg E, spoke in Spanish, tapped the left side of the pink headset. After she pressed the left side of the headset, AD provided an alternate meal order for an anonymous resident. An observation on 11/14/23 at 11:16 AM showed Cook F sitting at kitchen opening in Bldg G, on a stool, looking at cell phone and eating orange slices while direct care staff was redirecting a resident in the dining room. An observation on 11/15/23 at 12:25 PM, a test tray from Bldg G kitchen was served at a temperature of less than 132.8 degrees Fahrenheit. An observation on 11/15/23 at 12:32 PM, a test tray from Bldg H kitchen was served at a temperature of 141.7 degrees Fahrenheit. An observation on 11/15/23 at 12:50 PM, a test tray from Bldg E kitchen was served at a temperature of 100.9 degrees Fahrenheit. An observation on 11/16/23 at 8:35 AM showed MA B with cell phone propped up on the medication cart while passing out medications in the dining room. An observation on 11/16/23 at 1:18 PM showed Cook L with light blue earbuds in while working in the kitchen in Bldg H. An interview on 11/15/23 at 10:32 AM with Resident Council in Bldg E, 4 anonymous residents stated that the food could be hotter and there was too much of the same type of food. An interview on 11/15/23 at 10:32 AM with Resident Council in Bldg G, 8 anonymous residents revealed the food was terrible and some was not edible. Residents indicated that the food needed to be hotter and that there is too much rice. An interview on 11/16/23 at 10:38 AM with Cook I with CNA J translating. Cook I reported that cell phones cannot be used in front of residents and they must be used behind the facility out on the back patio. She reported that she had to sign a consent/policy for the use of her cell phone and that it had been a while and she did not remember if it was for this facility of the old facility that she used to work at. She reported that if she uses a cell phone if front of residents or at the incorrect time then she will get into trouble. She could not think of any other consequences of misusing cell phones. An interview on 11/16/23 at 10:44 AM with Cook K who reported that she is only to use her cell phone on break, that she has received no training on the use of cell phones at this facility, that she did sign a consent/policy when at her old facility, and that she received verbal training from DD. She reported that there would be no negative outcomes for using her cell phone during working hours or in front of a resident. An interview with DD on 11/16/23 was requested on 11/16/23 with Cook I and Cook K. Interview with DD was not obtained. Record review of Resident Council Minutes dated 9/11/23, 10/2/23, and 11/6/23 revealed that food was not being served hot. Record review of Resident Council Minutes dated 9/11/23, 10/2/23, and 11/6/23 revealed that cooks and CNA's were on their phones a lot. Record review of policy Cell Phone Usage by Employees, not dated, stated: POLICY: Employees of the facility shall not have on their person, nor shall they use personal cell phones in resident areas. PERSONNEL: This policy pertains to all facility employees. Policy stated that while on duty, employees shall keep their cell phones in their vehicle, in the employee break room, in their office or in their locker. Employees may use their personal cell phones while on break in these areas. Record review of Checking Temperatures of Food Received from the Main Kitchen, not dated, stated 1: the temperature of hazardous food prepared in the main kitchen for households will be checked and the temperature recorded. 3: any hot food found to be below 140 degrees Fahrenheit will be reheated for 165 degrees Fahrenheit for 15 seconds.

Based on interviews and record reviews, the facility failed to complete a MDS assessment every 92 day or within a timely manner for 3 (Residents #12, #18, and #37) of 12 residents reviewed for MDS assessments The facility failed to initiate a MDS assessment or complete an MDS assessment within 14 days after the ARD date for Residents #12, #18 and #37. This failure can place residents at risk of proper needs not being met, quality of care, assistive devices, and accuracy of assistance needed with activities of daily living. Findings included: Record review of Resident #12's face sheet, dated 11/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis (multi joint disease), hyperkalemia (high potassium levels in the blood), major depressive disorder, and chronic kidney disease. Review of Resident #12's MDS assessment, dated 5/15/23, showed a completion date of 5/31/23 (more than 14 days) and a MDS assessment dated [DATE] showed a completion date of 8/21/23. Record review of Resident #12's care plan, dated 11/8/23 shows a MDS assessment was not completed for the assessment. Record review of Resident #18's face sheet, dated 11/14/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, and weakness. Record review of Resident #18's MDS assessment, dated 7/10/23, revealed a completion date of 7/26/23 (more than 14 days). Record review of Resident #37's face sheet, not dated, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #37's admitting diagnoses is congestive heart failure. Record review of Resident #37's MDS assessment, dated 10/1/23, revealed a completed date of 10/25/23 (more than 14 days). In an interview on 11/5/23 at 2:19 PM, ADON indicated MDSN oversees MDS assessments and ADON and DON oversee care plans. In an interview on 11/15/23 at 2:22 PM with MDCN revealed she oversees MDS assessments. MDCN stated that she goes through each resident individually to set a schedule. MDCN stated she has 14 days to complete the care plan and it is completed when a RN signs it. Confirmed Resident #37's MDS assessment was late. MDCN indicated that a negative outcome is not having the proper things care planned. In an interview on 11/15/23 at 2:33 PM, ADON confirmed Resident #37's MDS assessment, dated 10/2/23 with a completed date of 10/25/23, was more than 14 days. ADON stated that a negative outcome was it could affect the resident's care. Record review of the RAI dated 10/1/23, under Chapter 2: Assessments for the RAI, pg 2-17, RAI OBRA-required Assessment Summary chart shows an admission assessment is to be completed on the 14th calendar day of a resident's admission. Pg 2-18 revealed a quarterly assessment must be completed ARD +14 calendar days.

Based on , interviews, and record reviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 7 (Residents #1, #3, #11, #12, #18, #25, and #37) of 12 residents reviewed for care plans. Residents #1, #3, #11, #12, #18, #25, and #37 did not have a comprehensive care plan completed 7 days after a comprehensive assessment. This failure places residents at risk for substandard quality of care, accuracy of needs, and assistance with activities of daily living. Findings included: Record review of Resident #1's face sheet, dated 11/16/23, revealed an [AGE] year-old female who was admitted to the facility originally on 2/17/2020 and readmitted [DATE]. Diagnoses included Dementia, major depressive disorder, type 2 diabetes, and epilepsy. Record review of Resident #1's MDS assessments revealed completion dates of 3/9/23, 6/4/23, and 8/27/23. MDS assessment dated [DATE] corresponded with a care plan completed on 3/20/23. MDS assessment dated [DATE] corresponded with a care plan completed on 6/20/23. MDS assessment dated [DATE] corresponded with a care plan completed on 9/14/23. Record review of Resident #3's face sheet, dated 11/16/23, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Diagnoses include Alzheimer's Disease, hypertension, and chronic heart failure. Record review of Resident #3's MDS assessment, completed 4/11/23, revealed a corresponding care plan dated 5/3/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #11's face sheet, dated 11/14/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Dementia, psychophysiological insomnia, delusional disorders, and post-traumatic stress disorder. Record review of Resident #11's MDS assessments and care plans revealed completion dates of 2/26/23, 6/4/23, and 8/23/23. MDS assessment on 2/26/23 had a corresponding care plan with a completed date of 3/20/23. MDS assessment on 6/4/23 had a corresponding care plan with a completed date of 6/20/23. MDS assessment dated [DATE] had a corresponding care plan with a completed date of 9/22/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #12's face sheet, dated 11/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis (multi joint disease), hyperkalemia (high potassium in the blood), major depressive disorder, and chronic kidney disease. Review of Resident #12's MDS assessments and care plans revealed completion dates of 5/31/23 and 8/21/23. MDS assessment completed on 5/31/23 revealed a corresponding care plan dated 5/3/23 indicating the care plan was completed before the comprehensive assessment. MDS assessment completed on 8/21/23 revealed a corresponding care plan completed on 7/31/23 indicating the care plan was completed before the comprehensive assessment. Record review of Resident #18's face sheet, dated 11/14/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, and weakness. Record review of Resident #18's MDS assessments and care plans revealed completion dates of 1/20/23, 4/23/23, and 7/26/23. MDS assessment completed on 1/20/23 revealed a corresponding care plan dated 2/22/23. MDS assessment completed 4/23/23 revealed a corresponding care plan dated 5/22/23. MDS assessment completed on 7/26/23 revealed a corresponding care plan dated 8/23/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted to facility on 5/20/21. Diagnoses include Combined systolic and diastolic heart failure, depression, and atrial fibrillation. Record review of Resident #25's MDS assessments revealed completed assessments on 12/9/22, 3/9/23, 6/12/23, and 9/7/23. MDS assessment completed on 12/9/22 revealed a corresponding care plan dated 12/7/22. MDS assessment completed 3/9/23 revealed a care plan dated 3/20/23. MDS assessment completed 6/12/23 revealed a corresponding care plan dated 6/20/23. MDS assessment completed 9/27/23 revealed a corresponding care plan dated 9/22/23. This revealed that care plans were completed prior to the completion of the comprehensive assessment or more than 7 days after the comprehensive assessment was completed. Record review of Resident #37's face sheet, not dated, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #37's admitting diagnoses is congestive heart failure. Record review of Resident #37's MDS assessment and care plan revealed the MDS assessment completed on 10/25/23 revealed a corresponding care plan dated 10/1/23 indicating the care plan was completed prior to the comprehensive assessment. In an interview on 11/15/23 at 2:19 PM, ADON indicated MDSN oversees MDS assessments and ADON and DON oversee care plans. In an interview on 11/15/23 at 2:33 PM with ADON and DON indicated the care plan is completed within 48 hours. ADON stated she believes the care plan is done 72 hours after assessment. DON stated that the care plan must be completed by 7 days via policy. ADON confirmed it was a completed date of 10/1/23 for Resident #37. ADON indicated the MDS was completed 10/25/23. DON looked at policy and stated the care plan goals are pulled from but not limited to MDS, prior assessments, etc. DON stated care plan is pull from a thorough assessment including the MDS. ADON confirmed the care plan was dated prior to MDS assessment completion. ADON confirmed dates of care plans for Resident #25 and stated the dates were not 7 days after the comprehensive assessments. ADON stated a negative outcome is it can affect the resident's care. DON stated it can affect the resident's care. Record review of facility policy titled Care Plans- Comprehensive, not dated, states: 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to, the MDS. 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 4 (Prairie House medication room, Cottonwood House medication room, Cottonwood House medication cart, and Sunset House medication room) of 6 medication storage areas reviewed for medication storage. The Prairie House Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Sunset Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication cart contained 3 insulin pens that had no medication labels. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: Record review of the Prairie House Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-6-2023-32 degrees Fahrenheit 11-7-2023-30 degrees Fahrenheit 11-11-2023-26 degrees Fahrenheit 11-12-2023-26 degrees Fahrenheit 11-14-2023-26 degrees Fahrenheit During an observation on 11-15-2023 at 08:31 AM of Prairie House Household Medication room refrigerator with LVN A present were the following: 2-Lantus Insulin bottles (manufacturer recommended storage between 36-46 degrees). 1-Humalog Insulin bottle (manufacturer recommended storage between 36-46 degrees). 1-Acetaminophen suppository box (with instructions to store between 68-77 degrees). 1-Bisacodyl suppository box unopened (with instructions to store between 68-77 degrees) During an interview on 11-15-2023 at 08:34 AM LVN A verified the current temperature in the Prairie House Household medication storage refrigerator was 42-43 degrees, that night shift is responsible for monitoring the refrigerator temperatures, and that several temperatures this month had been documented below freezing. LVN A reported that the medications in the Prairie House Household Medication room refrigerator such as Acetaminophen and Bisacodyl needed to be stored at room temperature, that if any of the medications currently present in the refrigerator were to freeze, they would not be affective, and they could affect resident treatment and condition. Record review of the Cottonwood Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-1-2023-26 degrees Fahrenheit. 11-3-2023-32 degrees Fahrenheit. 11-4-2023-32 degrees Fahrenheit. 11-11-2023-28 degrees Fahrenheit. 11-14-2023-26 degrees Fahrenheit. During an observation on 11-15-2023 at 08:46 AM of the Cottonwood Household Medication room refrigerator the following were observed: 1-Tuberculin diluted apiol (with instruction to store between 36-46 degrees) 2-Lantus insulins (with instructions to store between 36-46 degrees) 1-NovoLog flex pen (with instructions to store between 36-46 degrees) 1-Flu vaccine syringe (with instructions to store between 36-46 degrees) 1-Bisacodyl suppository box (with instructions to store between 68-77 degrees) 1-Promethazine suppository (with instruction to store in refrigerator. Do not freeze) 1-Enbrel (with instructions to store between 36-46 degrees) 4-Basaglar Insulin pens (with instructions to store between 36-46 degrees) 2-NovoLog pens (with instructions to store between 36-46 degrees) During an interview on 11-15-2023 at 09:33 AM MA B verified that the medications that were stored in the Cottonwood Household Medication room refrigerator were documented below freezing by the night shift and MA B reported that if a medication was frozen it would reduce the strength of the medication and it would not be as effective, MA B said that it could and would affect the residents care and the residents would not receive the right dose, or it would be less effective. Record review of the Sunset Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-4-2023-28 degrees Fahrenheit 11-14-2023-32 degrees Fahrenheit During an observation on 11-15-2023 at 08:46 AM of the Sunset Household Medication room refrigerator the following was observed: 1-Acetaminophen suppository box (with instructions to store between 68-77 degrees). During an interview on 11-15-2023 at 09:33 AM LVN C verified that the medication that was stored in the Sunset Household Medication room refrigerator was documented at below freezing by the night shift and reported that if a medication were to be frozen or stored below the temperature it was listed to be stored at then that medication would not be as effective. LVN C reported that freezing the Acetaminophen medication in the refrigerator would not give residents their needed benefit, that the Acetaminophen would not be effective. During an observation on 11-15-2023 at 11:07 AM of the Cottonwood Household Medication Cart with LVN A noted were 1-Novolog N insulin pen, 1-Novolog R inulin pen, and 1-Basaglar Insulin pen. Upon review it was noted that there was no medication label information on any of the three insulin pens. Noted was the last name handwritten in marker of the resident on the Basaglar Insulin pen. None of the three insulin pens contained the prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. During an interview on 11-15-2023 at 11:11 AM LVN C verified that there was no resident information on the three insulin pens that were on the Cottonwood Household Medication Cart. LVN C said that if a new nurse or an agency nurse was to administer the insulin, they could have difficulty telling who the insulin is for, and that she (LVN C) was aware of who the insulin was for because she had worked with the residents for awhile. LVN C stated, I see where someone new could give the wrong insulin. During an interview on 11-16-2023 at 09:39 AM the DON reported that the recommended storage temperature in the medication room storage refrigerator is 36-46 degrees. The DON said that if the temperature is out of that range, then it needs to be reported immediately The DON said that if a medication is stored outside the ranges that that medication is listed for then that medication would need to be discarded. The DON reported that if a medication is stored outside of the recommended ranges, then that could affect the medications potency, and the residents may or may not get the appropriate mediation. The DON verified that this could affect resident care. The DON reported that all current refrigerator medication thermometers have been replaced and all the medications that were stored had been discarded. The DON reported that if a medication is not labeled correctly then a medication error could result and there could be potential harm to a resident. Record review of the facility provided polity titled, Storage of Medication undated, revealed the following: Policy Statement- The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation- 3. Drugs container that have missing, incomplete, improper, or incorrect label shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secure location. Record review of the facility provided polity titled, Labeling of Medication Containers undated, revealed the following: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulation. Policy and Interpretation: 2. All medication packaging or container that are inadequately or improperly labeled shall be returned to the issuing pharmacy 3. Labels for individual drug containers shall include all necessary information, sch as: a. The Resident name b. The prescribing physician name c. The name, address, and telephone number of the issuing pharmacy d. The name, strength, and quantity of the drug e. The prescription number f. The date the medication was dispensed. g, Appropriate accessory, and cautionary statements

Based on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #13) of 12 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #13 was admitted to hospice. This failure to ensure comprehensive and accurate assessments are completed could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition. Finding include: Record review of Resident #13's face sheet dated 11-14-2023 revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements to include tremors), dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified psychosis (a mental disorder characterized by a disconnection from reality), major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety(a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of Resident #13's last MDS was a quarterly completed 7-25-2023 listing her with a BIMS that was not evaluated due to memory problems and she had a functionality of requiring one to two-person assistance with all her activities. Record review of Resident #13's MDS Tracking List revealed she had an Annual MDS completed on 4-24-2023 and a Quarterly MDS completed on 7-25-2023. No other MDS's were completed between these two dates. Record review of Resident #13's 4-24-2023 annual MDS revealed the following: Section O-Special Treatment, Procedures, and Programs: Other-K. Hospice-Resident #13 is not marked for having Hospice. Record review of Resident #13's 7-25-2023 Quarterly MDS revealed the following: Section O-Special Treatment, Procedures, and Programs: Other-K. Hospice-Resident #13 is marked for having Hospice while a resident. Record review of Resident #13's Order Summary Report printed 11-16-2023 with Active Orders as of 11-16-2023 revealed the following order: Admit to Hospice-Order Date: 5-18-2023. During an interview by phone (because all MDS assessments are completed offsite by a contract company) on 11-16-2023 at 09:16 AM the MDS Coordinator reviewed Resident #13's chart and verified that a significant change of condition was not completed when hospice was ordered, that a significant change of condition should have been completed within 14 days of adding hospice when it was ordered, and that the individual responsible for completing that significant change of condition MDS no longer worked for their company so the MDS Coordinator did not know why the significant change of condition MDS was not completed. The MDS Coordinator reported that not completing the significant change of condition MDS for this resident could result in the facility not being able to track the resident's condition and care. The MDS Coordinator reported that the policy used for the required significant change of condition MDS would have been the RAI manual. During an interview on 11-16-2023 at 09:43 AM the DON with the ADON present reported that if a residents MDS is not done correctly then there will not be continuity of care. The DON reported that the ADON is currently being trained so that they will no longer need an offsite agency due to the repeated issues with MDS's not being completed correctly. During an interview on 11-16-2023 at 09:50 AM the Administrator when advised that Resident #13 did not have a significant change of condition completed 5-2023 when Resident #13 was put on hospice stated, We will get that corrected immediately. Record review of the RAI Manual October 2023 revealed the following instructions: Comprehensive Assessments: 03. Significant Change in Status Assessment (SCSA) o The ARD (Assessment Reference Date) must be less than or equal to 14 days after the IDT's (Interdisciplinary Team) determination that the criteria for an SCSA are met (determination date + 14 calendar days).

Based on observation, interview, and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 8 of 19 residents (Residents #1, #23, #24, #26, #31, #33, #36 and #39) whose assessments were reviewed. The MDS assessments for Residents #1, #23, #24, #26, #31, #33, #36 and #39 indicated that the residents had bed rails that were being used as physical restraints when, although they did have bed rails on their beds, they were not being used or acting as physical restraints. This failure could place residents at risk of not to receiving necessary care or receiving inappropriate care for their needs and/or condition(s). Findings Include: Resident #1 Record review of Resident #1's face sheet, dated 06/30/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS assessment, dated 03/17/2021, revealed that the resident had a BIMS score of 2, indicating severe cognitive impairment. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident # 1's current care plan, undated, revealed the following interventions: The resident is able to: repositions self in bed with use of side rails. AMBULATION: The resident is able to: ambulate with extensive assist. Staff will ensure her wheelchair is in good working condition and ensure she is safe while she wonders around the home in her wheelchair. During an observation on 06/28/21 at 11:00 AM Resident #1 was observed getting ready for lunch in the dining area. During the survey, Resident #1 was consistently observed in the dining or living area and was not observed in his bed. On 06/28/21 at 11:15 AM an interview with Resident #1 was attempted. Resident #1 smiled but did not respond to any questions. Resident #23 Resident #23 is a 78 y.o. female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23's MDS assessment, dated 06/16/2021, revealed that the resident had a BIMS score of 14 out of 15, indicating no cognitive impairment. Section G of the MDS indicated that the resident required extensive assistance from 1 staff member with bed mobility, transfers, and dressing; extensive assistance from 1 staff member with toilet use; and was independent with personal hygiene. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #23's current care plan, dated 2/18/21, revealed the following interventions: BED MOBILITY: The resident is able to help turn self independently. SIDE RAILS: half rails up as per doctors order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury. The resident is able to propel self in wheelchair. Record review of Resident #23's active physician orders, dated 06/28/2021, revealed an order with a start date of 09/9/2019 that read, Upper siderails for turning and repositioning PRN. Record review of document in chart of Resident # 23 titled Side Rail Evaluation, dated 06/07/2021, reveled the following in part: 3. Is the resident physically able to release side rails? no 6. Is the resident able to get in/out of bed without assistance? no 7. Is the resident able to get in/out of bed safely without assistance? no 10. Is the resident able to move their own body? Yes 11. Will the resident use the side rails for positioning or support? Yes 12. Does the side rail help the resident rise from lying to a sitting/standing position? Yes During an observation on 06/28/2021 at 11:16 AM, Resident #23 was in her room sitting in a wheelchair. Her bed had two side rails on it (one on each side), both in the up position, and both about a quarter of the bed length long. Resident #23 reported that she likes having bed rails on her bed because she needs them to move around in bed. During an interview on 06/29/2021 at 9:10 AM Resident #23 reported that the bed rails on her bed do not hinder or restrict her freedom of movement or ability to access her own body in any way. She reported that her ability to transfer in and out of bed is not affected by the bed rails because she has to have help from staff for those tasks anyway. Resident #24 Record review of Resident #24's face sheet, dated 06/30/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #24's MDS assessment, dated 05/17/2021, revealed that the resident had a BIMS score of 13, indicating no cognitive impairment. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #24's active physicians orders, dated 06/30/2021, revealed an order with a start date of 02/02/2021 that read, May use side rails PRN to assist with repositioning. During an observation and interview on 06/28/2021 at 11:20 AM, Resident #24 was in her room lying in bed watching tv. There were four side rails on the bed (two on each side) that were a quarter of the bed length long. The top two rails were in the up position while the bottom two were in the down position. Resident #24 stated she likes having her bed rails and she uses them to reposition herself. Resident #26 Record review of Resident #26's face sheet, dated 06/30/2021, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's MDS assessment, dated 05/22/2021, revealed that the resident had a BIMS score of 3, indicating severe cognitive impairment. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #26's active physicians orders, dated 06/30/2021, revealed an order with a start date of 11/09/2020 that read, May use side rails PRN to assist with repositioning. During an observation on 06/28/2021 at 10:42 AM, Resident #26 was in his room lying in bed. There were four side rails on the bed (two on each side) that were a quarter of the bed length long. The top two rails were in the up position while the bottom two were in the down position. Resident #31 Record review of Resident #31's face sheet, dated 06/28/2021, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's MDS assessment, dated 05/29/2021, revealed that the resident had a BIMS score of 14, indicating no cognitive impairment. Section G of the MDS indicated that the resident required no setup or physical help from staff with any ADLs, including transfers and bed mobility. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #31's current care plan, not dated, revealed the following interventions: SIDE RAILS: full rails up as per resident like and doctors order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (FREQ) and as necessary to avoid injury. Able to propel self in w/c. Feeds self. Resident performs adls independently with little assist from staff, able to walk in room and transfer self to toilet and bed. able to perform hygiene and oral care independently. dressing and personal care. Record review of Resident #31's active physician orders, dated 06/28/2021, revealed an order with a start date of 10/29/2019 that read, Upper siderails for turning and repositioning PRN. Record review of document in chart of Resident #31 titled Side Rail Evaluation, dated 05/28/2021, reveled the following in part: 3. Is the resident physically able to release side rails? Yes 6. Is the resident able to get in/out of bed without assistance? Yes 7. Is the resident able to get in/out of bed safely without assistance? Yes 10. Is the resident able to move their own body? Yes 11. Will the resident use the side rails for positioning or support? Yes 12. Does the side rail help the resident rise from lying to a sitting/standing position? Yes During an observation on 06/29/2021 at 8:45 AM, Resident #31 was in his room lying in bed with his eyes closed. There were four side rails on the bed (two on each side) that were a quarter of the bed length long. The top two rails were in the up position while the bottom two were in the down position. During an observation and interview on 06/29/2021 at 2:05 PM, Resident #31 was in his room sitting on the side of the bed. There were still four quarter length bed rails on the bed (two on each side of the bed). The top two rails were in the up position while the bottom two were in the down position. Resident #31 reported that he requested to have bed rails on his bed, and he denied that they restrict him in any way. Resident #31 reported that the bed rails do not hinder his freedom of movement, ability to transfer to and from his bed, or ability to access his own body. He reported that the bed rails, in his opinion, help him to get in and out of bed independently. Resident #33 Record review of Resident #33's face sheet, dated 06/28/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's MDS assessment, dated 06/09/2021, revealed that the resident had a BIMS score of 15, indicating no cognitive impairment. Section G of the MDS indicated that the resident required extensive assistance from 2 staff members with bed mobility, transfers, and dressing; limited assistance from 2 staff members with toilet use; and limited assistance from one staff member with personal hygiene. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #33's current care plan, not dated, revealed the following interventions: BED MOBILITY: The resident is able to help turn self with assistance from side rail. SIDE RAILS: half rails up as per doctors order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury. The resident requires the use of w/c to complete adls. Staff assistance x2 for transfers. Requires assistance of 1 for bathing and dressing. resident independent in personal hygiene and oral care. Resident feeds self. Record review of Resident #33's active physician orders, dated 06/28/2021, revealed an order with a start date of 09/11/2019 that read, Upper siderails for turning and repositioning PRN. Record review of document in chart of Resident #33 titled Side Rail Evaluation, dated 06/07/2021, reveled the following in part: 3. Is the resident physically able to release side rails? no 6. Is the resident able to get in/out of bed without assistance? no 7. Is the resident able to get in/out of bed safely without assistance? no 10. Is the resident able to move their own body? Yes 11. Will the resident use the side rails for positioning or support? Yes 12. Does the side rail help the resident rise from lying to a sitting/standing position? Yes During an observation on 06/28/2021 at 10:46 AM, Resident #33 was in her room sitting in a wheelchair. Her bed had two side rails on it (one on each side), both in the up position, and both about a quarter of the bed length long. Resident #33 reported that she likes having bed rails on her bed because she needs them to move around in bed. During an interview on 06/29/2021 at 10:10 AM Resident #33 reported that the bed rails on her bed do not hinder or restrict her freedom of movement or ability to access her own body in any way. She reported that her ability to transfer in and out of bed is not affected by the bed rails because she has to have help from staff for those tasks anyway. Resident #36 Record review of Resident #36's face sheet, dated 06/30/2021, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #36's MDS assessment, dated 06/08/2021, revealed that the resident is rarely/never understood. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #36's care plan, undated, revealed the following interventions: Ensure that The resident is wearing appropriate footwear ( slipper socks or slip on shoes when ambulating. Record review of Resident #36's active physician orders, dated 06/30/2021, revealed an order with a start date of 09/02/2019 that read, Upper siderails for turning and repositioning PRN. During an observation on 06/28/21 at 11:00 AM Resident #36 was observed getting ready for lunch in the dining area. During the survey, Resident #36 was not observed to be in his bed during the day. On 06/28/21 at 11:07 AM an interview with Resident #36 was attempted. Resident #36 was unable to be understood. Resident #39 Resident #39 is an 81 y.o. male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #39's MDS assessment, dated 06/14/2021, revealed that the resident had a BIMS score of 99 which indicates cognition could not be assessed. Section G of the MDS indicated that the resident is totally dependent on assistance from 2 staff members with bed mobility, transfers, and dressing; extensive assistance from 2 staff members with toilet use; and was dependent on staff for personal hygiene. Section P0100 of the MDS indicated that the resident had physical restraints in the form of bed rails, used daily. Record review of Resident #39's current care plan, dated 6/15/21, revealed the following interventions: BED MOBILITY: The resident requires assistance of 2 for transferring assistance . SIDE RAILS: Full/half rails up as per doctors order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury. The resident is able to propel self in wheelchair at a slow speed Record review of Resident #39's active physician orders, dated 06/28/2021, revealed an order with a start date of 3/4/20 that read, Upper siderails for turning and repositioning PRN. Record review of document in chart of Resident #39 titled Side Rail Evaluation, dated 06/07/2021, reveled the following in part: 3. Is the resident physically able to release side rails? no 6. Is the resident able to get in/out of bed without assistance? no 7. Is the resident able to get in/out of bed safely without assistance? no 10. Is the resident able to move their own body? Yes 11. Will the resident use the side rails for positioning or support? Yes 12. Does the side rail help the resident rise from lying to a sitting/standing position? Yes During an observation and interview on 06/28/2021 at 11:30 AM, Resident #39 was in his room sitting in his bed. His bed had two side rails on it (one on each side), both in the up position, and both about a quarter of the bed length long. Resident #39 stated his side rails do not bother him and he uses them to move around. During an interview on 06/28/2021 at 1:53 PM, MDSC confirmed that multiple facility residents that have bed rails on their beds had those bed rails coded as physical restraints on their MDS assessments. MDSC reported that the bed rails were being used as mobility aids, and when asked why the bed rails were coded as physical restraints, MDSC stated, I've never done it that way before, but when I came here, they told me to code it that way. During an interview on 06/30/2021 at 8:59 AM, MDSC reported that she is responsible for completing MDS assessments and DON is the RN that ensures the accuracy of MDS assessments. MDSC again confirmed that multiple facility residents with bed rails had their bed rails coded as physical restraints in their MDS assessments. When asked to reiterate why she chose to code the bed rails as physical restraints, she replied, They told me that you have to code them as restraints even though they are enablers. When asked to clarify who exactly instructed her to code all bed rails as physical restraints, MDSC reported that it was DON who told her to do so. When asked if she felt as if the residents' bed rails were currently acting as restraints, MDSC replied, to me they're not restraints they're enablers. After reviewing the RAI manual regarding section P, MDSC was asked if she felt that all resident bed rails should be coded as physical restraints in section P and replied, no. MDSC was asked individually about each resident (Residents #1, # 23, #24, #26, #31, #33, #36 and #39), and she indicated that, in her opinion, none of those residents' bed rails affect their freedom of movement, ability to transfer, or ability to access their own bodies. MDSC was asked about the potential consequences of MDS assessment inaccuracies and replied, recoupment of money. MDSC was asked if she felt the MDS assessments of Residents #1, #23, #24, #26, #31, #33, #36, and #39 were accurate in section P, and she replied, not with your interpretation of the RAI manual. MDSC was asked if the ADM was aware that bed rails were being coded as physical restraints on MDS assessments and replied, I don't know. MDSC was asked if the facility has a policy about being restraint free and replied, I couldn't tell you. I know it's the goal of all nursing homes. During an interview on 06/30/2021 at 9:29 AM, DON reported that MDSC completes the MDS assessments and she signs off on them that they are accurate and transmits them. DON was asked if resident bed rails are being used as physical restraints and replied, no. DON reported that a bed rail acts as a physical restraint for a resident when it prevents the resident from getting in and out of bed. DON was asked under what circumstances bed rails should be coded on MDS assessments as physical restraints and replied, I honestly don't know the answer to that. DON was asked individually about each resident (Residents #1, #23, #24, #26, #31, #33, #36 and #39), and she indicated that, in her opinion, none of those residents' bed rails affect their freedom of movement, ability to transfer, or ability to access their own bodies. DON was asked if those residents' bed rails are acting as physical restraints and replied, no, not really, they're for positioning. DON was asked if the MDS assessments for those residents were currently accurate and replied, not entirely. DON reported that section P0100 of those residents' MDS assessments should have been coded with zero physical restraints. DON was asked about the potential consequences of inaccurate MDS assessments and replied, there's a fine, I don't know. DON was asked about potential consequences for residents and reported it could affect compensation and care planning. DON was asked if ADM was aware that bed rails were being coded as restraints on MDS assessments and reported that she did not know. DON was asked if the facility has a policy about being a restraint free facility and replied, I think so. During an interview on 06/30/2021 at 9:50 AM, ADM reported that he has never personally completed an MDS assessment and had limited knowledge about them. ADM was asked about the facility policy regarding physical restraints and replied, we try not to use physical restraints. ADM reported that the facility considers itself to be a restraint free facility. During an interview on 06/30/2021 at 12:43 PM, DON reported that the facility does not have a written policy or procedure regarding MDS assessments but reported that they follow the RAI manual. Record review of facility provided policy titled Use of Side Rails Policy, not dated, revealed in part: Policy: It is the policy of this facility that all resident will be free from chemical and physical restraints. Record review of document by Centers for Medicare and Medicaid Services titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual: Version 1.17.1, dated October 2019, reflected in part: [on page P-1] DEFINITION PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. [on page P-5] Coding Tips and Special Populations Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block three-quarters to the whole length of the mattress from top to bottom, etc.). Include in this category enclosed bed systems. - Bed rails used as positioning devices. If the use of bed rails (quarter-, half- or three-quarter, one or both, etc.) meet the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint at P0100A. - Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. For residents who have no voluntary movement, the staff need to determine if there is an appropriate use of bed rails. Bed rails may create a visual barrier and deter physical contact from others. Some residents have no ability to carry out voluntary movements, yet they exhibit involuntary movements. Involuntary movements, resident weight, and gravity's effects may lead to the resident's body shifting toward the edge of the bed. When bed rails are used in these cases, the resident could be at risk for entrapment. For this type of resident, clinical evaluation of alternatives (e.g., a concave mattress to keep the resident from going over the edge of the bed), coupled with frequent monitoring of the resident's position, should be considered. While the bed rails may not constitute a physical restraint, they may affect the resident's quality of life and create an accident hazard.

Based on interviews and record reviews the facility failed to ensure the right to be free from abuse was provided for 1 or 5 residents (Resident #2) reviewed for abuse. CNA A hit Resident #2 on his chest resulting in a hand print and bruising that lasted 2 weeks. This failure could place residents at risk of abuse, injury, fear, and hopelessness. Findings include: Record review of Resident #2's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #2's quarterly MDS dated [DATE] documented Resident #2 had severe cognitive impairment and displayed verbal and physical behaviors. Record review of Resident #2's Care Plan last revised on 6/26/20 documented the following: Focus: o The resident is resistive to care refuses showers, meals and ADL assistance often. Prefers certain staff for ADL assistance, verbally and physically aggressive at times. Refuses meals, meds and getting out of bed often. Date Initiated: 04/01/2020 Revision on: 06/26/2020 Interventions/Tasks: o Allow the resident to make decisions about treatment regime, to provide sense of control. Date Initiated: 04/01/2020 o Encourage as much participation/interaction by the resident as possible during care activities. Date Initiated: 04/01/2020 o Give clear explanation of all care activities prior to an as they occur during each contact. Date Initiated: 04/01/2020 o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 04/01/2020 o Praise the resident when behavior is appropriate. Date Initiated: 04/01/2020 o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Date Initiated: 04/01/2020 Record review of the facility's Provider Investigation Report, signed by the ADM on 9-17-20, documented the following: Investigation Summary - Attached are statements from (CNA A, CNA B, and LVN C). When interviewed more closely by this administrator and DON (name removed) and extensively on Tuesday, 9/15/20, (CNA B) proved to be more descriptive of the situation even indicating that there was a slight pause as (CNA A) responded verbally to the resident after being hit and then raised her hand high in the air before the slap occurred, both of which indicated to this administrator that the hand slap was more than a kneejerk reaction as previously described. She also maintains that she had told (CNA A) to report the incident to the charge nurse or she would do so. Investigation Findings - Confirmed Provider Action Taken Post-Investigation - On 09/15/2020, administrator called (CNA A) and informed her that her employment with Edward Abraham Memorial Home was being terminated effective immediately. Statement written and signed by CNA A on 9/12/20 documented the following: An incident with (Resident #2) happened around 3:30 am. He was very combative and threating (sic) even after we explained to him more than once what (CNA B) (the other aide) and I were trying to do, which was changing him. He got more combative, then starting (sic) swinging his fists at us as we continued to clean him and do his care. At one point as we rolled (Resident #2) he hit me (CNA A) in the right eye and before I even thought I hit him in the chest with the flat of my hand Statement written and signed by LVN C on 9/12/20 documented the following: (CNA A) came to this nurse and reported that while herself and (CNA B) were changing (Resident #2), the resident hit (CNA A) in the face. (CNA A) states, out of instinct, she slapped resident on the chest. This nurse went to residents (sic) room to assess resident. Resident has a hand print on the right side of his chest. Resident seems agitated and is cursing at this time . At approximately 0354 (3:54 am), this nurse called the administrator and reported the incident to him. This nurse was advised to have both aides to write a statement as well as myself Record review of Resident #2's Weekly Skin Integrity Review documented the following: Skin Condition: Skin Intact, Bruises - Right upper chest/green in color. Dated 9/15/20 Skin Condition: Bruises - Fading bruise to right pectoral muscle. Dated 9/25/20 During an interview with LVN C on 10/8/20 at 7:24 pm, LVN C said on 9/12/20 around 3:30 am, she was getting ready to pull the morning meds on the night of the incident when CNA A came up to her and said, You need to come with me. LVN C asked CNA A why and CNA A said, We were changing (Resident #2) and he became combative and I slapped him on the chest and there is a red mark. LVN C said she went to look at him and he was clearly upset. She was able to look at his chest and could see a hand print on the right side of his chest. LVN C said she called the ADM to report it. During an interview with ADM on 10/8/20 at 8:12 pm, ADM said what he was first told of the incident was that it was just a reflex response by CNA A after being hit by Resident #2, but during the investigation he found it may not have been a reflex after all. When he interviewed CNA B, who was in the room with CNA A and Resident #2 when the incident occurred, she gave more details than were written in her statement. CNA B said CNA A raised her hand real high back and then hit him. ADM said he didn't think that sounded like a knee jerk response, so he terminated CNA A's employment with the facility. During an interview with CNA B on 10/8/20 at 9:08 pm, CNA B said she and CNA A were doing their 2:00 am rounds. Resident #2 was the last resident on their rounds. CNA B said Resident #2 was already grumpy. She usually has a good rapport with him. He is very modest also and likes to stay covered up. He was dirty, so they had to change him. He hit CNA A in the face and CNA A told him to stop and you can't hit me. Resident #2 went to swing again and that's when CNA A hit him. CNA A first told him you can't be doing that and then pulled her hand up high and she hit him. CNA B said, She hit him hard. It was horrible. CNA B said he really started swinging then. She told CNA A to get out and she would finish cleaning him up. When she came out of Resident #2's room, she found CNA A and told her, If you don't say something to the charge nurse, I will. Once CNA A calmed down she went in the med room where LVN C was and CNA A told her she hit a resident. LVN C told them to write a statement and they slipped it under the ADM's door. CNA B said she didn't know CNA A left a hand print on Resident #2's chest until the next night when she went back to work. When she went to see Resident #2, she could see the hand print on the right side of his chest. During an interview at 8:40 am on 10/8/20 with LVN D, she said she is the one who normally does the weekly skin assessments. She said on 9/25/20 she did a skin assessment on Resident #2 and he still had a bruise to the right chest area that was fading. During an interview with the ADM on 10/9/20 at 10:11 am, ADM was asked if the facility offers staff training on how to handle residents when they become combative. ADM said during orientation they are taught to try to approach residents at the resident's level and not to be domineering. During an interview with CNA A on 10/9/20 at 10:29 am, CNA A said she didn't know why she hit Resident #2. She said he was always real combative, but she could usually work with him and provide care. She said she and another CNA were going to change him because he was wet. She said she had the draw sheet and the pad and explained what they had to do and why. She went to roll him over using the draw sheet and he got me right in the eye. I have no idea why, I popped him on the chest and said, 'That's enough!' She said it was a knee jerk reaction. She said he was the last one on their rounds. She said she has never acted like that before. CNA A said, It was probably from exhaustion catching up with me and I didn't notice it. She said, There is no excuse. She said she was not given any training at the facility on how to handle combative residents. She was never told what was on his care plan on what they were supposed to do when he rejects care. Record review of the facility's undated Abuse Prevention Program, Polices and Procedures, documented the following: Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement - Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any sign and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Abuse Investigations Policy Statement - All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 7. Employees of this facility who have bee (sic) accused of resident abuse may be suspended from duty until the results of the investigation have been reviewed by the administrator. Reporting Abuse to Facility Management 7. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record.

Based on interviews and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse for 1 or 5 residents (Resident #2) reviewed for abuse. CNA A hit Resident #2 on his chest resulting in a hand print and bruising that lasted 2 weeks. The facility failed to prevent further potential abuse when CNA A was assigned a different hall and allowed to finish out her shift after she hit Resident #2 on his chest. This failure could place residents at risk of abuse, injury, fear and hopelessness. Findings include: Record review of the facility's undated Abuse Prevention Program, Polices and Procedures, documented the following: Protection of Residents During Abuse Investigations Policy Statement - Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, resident will be protected from harm by the following measures: a. Employees' accused of participating in the alleged abuse may be suspended without pay until the administrator has reviewed the findings of the investigation. Additional supervision maybe required ensuring residents safety. Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement - Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any sign and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Abuse Investigations Policy Statement - All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 7. Employees of this facility who have bee (sic) accused of resident abuse may be suspended from duty until the results of the investigation have been reviewed by the administrator. Reporting Abuse to Facility Management 7. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. Record review of Resident #2's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #2's quarterly MDS dated [DATE] documented Resident #2 had severe cognitive impairment and displayed verbal and physical behaviors. Record review of Resident #2's Care Plan last revised on 6/26/20 documented the following: Focus: o The resident is resistive to care refuses showers, meals and ADL assistance often. Prefers certain staff for ADL assistance, verbally and physically aggressive at times. Refuses meals, meds and getting out of bed often. Date Initiated: 04/01/2020 Revision on: 06/26/2020 Interventions/Tasks: o Allow the resident to make decisions about treatment regime, to provide sense of control. Date Initiated: 04/01/2020 o Encourage as much participation/interaction by the resident as possible during care activities. Date Initiated: 04/01/2020 o Give clear explanation of all care activities prior to an as they occur during each contact. Date Initiated: 04/01/2020 o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 04/01/2020 o Praise the resident when behavior is appropriate. Date Initiated: 04/01/2020 o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Date Initiated: 04/01/2020 Record review of the facility's Provider Investigation Report, signed by the ADM on 9-17-20, documented the following: Investigation Summary - Attached are statements from (CNA A, CNA B, and LVN C). When interviewed more closely by this administrator and DON (name removed) and extensively on Tuesday, 9/15/20, (CNA B) proved to be more descriptive of the situation even indicating that there was a slight pause as (CNA A) responded verbally to the resident after being hit and then raised her hand high in the air before the slap occurred, both of which indicated to this administrator that the hand slap was more than a kneejerk reaction as previously described. She also maintains that she had told (CNA A) to report the incident to the charge nurse or she would do so. Investigation Findings - Confirmed Provider Action Taken Post-Investigation - On 09/15/2020, administrator called (CNA A) and informed her that her employment with Edward Abraham Memorial Home was being terminated effective immediately. Statement written and signed by CNA A on 9/12/20 documented the following: An incident with (Resident #2) happened around 3:30 am. He was very combative and threating (sic) even after we explained to him more than once what (CNA B) (the other aide) and I were trying to do, which was changing him. He got more combative, then starting (sic) swinging his fists at us as we continued to clean him and do his care. At one point as we rolled (Resident #2) he hit me (CNA A) in the right eye and before I even thought I hit him in the chest with the flat of my hand Statement written and signed by LVN C on 9/12/20 documented the following: (CNA A) came to this nurse and reported that while herself and (CNA B) were changing (Resident #2), the resident hit (CNA A) in the face. (CNA A) states, out of instinct, she slapped resident on the chest. This nurse went to residents (sic) room to assess resident. Resident has a hand print on the right side of his chest. Resident seems agitated and is cursing at this time . At approximately 0354 (3:54 am), this nurse called the administrator and reported the incident to him. This nurse was advised to have both aides to write a statement as well as myself Record review of Resident #2's Weekly Skin Integrity Review documented the following: Skin Condition: Skin Intact, Bruises - Right upper chest/green in color. Dated 9/15/20 Skin Condition: Bruises - Fading bruise to right pectoral muscle. Dated 9/25/20 During an interview with LVN C on 10/8/20 at 7:24 pm, LVN C said on 9/12/20 around 3:30 am, she was getting ready to pull the morning meds on the night of the incident when CNA A came up to her and said, You need to come with me. LVN C asked CNA A why and CNA A said, We were changing (Resident #2) and he became combative and I slapped him on the chest and there is a red mark. LVN C said she went to look at him and he was clearly upset. She was able to look at his chest and could see a hand print on the right side of his chest. LVN C said she called the ADM to report it. ADM instructed her to get everyone to write a statement on what happened and to not let CNA A go back in Resident #2's room. LVN C said she didn't know she had the authority to clock CNA A out and send her home. LVN C said after CNA A finished writing her statement, there was about an hour left on the shift and CNA A left at the end of her shift. LVN C said she didn't know if CNA A was suspended because she was going on her days off then for 3 days anyway but did know she never came back to work. LVN C said she has since been told to send the alleged perpetrator of abuse or neglect home immediately after learning of an allegation of abuse or neglect. During an interview with ADM on 10/8/20 at 8:12 pm, ADM said immediately after the incident, CNA A was moved to the short hall and the other aide worked the hall where Resident #2 resided. ADM said he had never had any problems with CNA A before. Resident #2 was very hard to care for and was very difficult. ADM said, The other residents were safe because no one else hits her. I didn't think she was a risk to others. The hand print dissipated pretty quickly. She never worked another shift. ADM said what he was first told of the incident was that it was just a reflex response by CNA A after being hit by Resident #2, but during the investigation he found it may not have been a reflex after all. When he interviewed CNA B, who was in the room with CNA A and Resident #2 when the incident occurred, she gave more details than were written in her statement. CNA B said CNA A raised her hand real high back and then hit him. ADM said he didn't think that sounded like a knee jerk response, so he terminated CNA A's employment with the facility. During an interview with CNA B on 10/8/20 at 9:08 pm, CNA B said she and CNA A were doing their 2:00 am rounds. Resident #2 was the last resident on their rounds. CNA B said Resident #2 was already grumpy. She usually has a good rapport with him. He is very modest also and likes to stay covered up. He was dirty, so they had to change him. He hit CNA A in the face and CNA A told him to stop and you can't hit me. Resident #2 went to swing again and that's when CNA A hit him. CNA A first told him you can't be doing that and then pulled her hand up high and she hit him. CNA B said, She hit him hard. It was horrible. CNA B said he really started swinging then. She told CNA A to get out and she would finish cleaning him up. When she came out of Resident #2's room, she found CNA A and told her, If you don't say something to the charge nurse, I will. Once CNA A calmed down she went in the med room where LVN C was and CNA A told her she hit a resident. LVN C told them to write a statement and they slipped it under the ADM's door. CNA B said she didn't know CNA A left a hand print on Resident #2's chest until the next night when she went back to work. When she went to see Resident #2, she could see the hand print on the right side of his chest. During an interview at 8:40 am on 10/8/20 with LVN D, she said she is the one who normally does the weekly skin assessments. She said on 9/25/20 she did a skin assessment on Resident #2 and he still had a bruise to the right chest area that was fading. During an interview with the ADM on 10/9/20 at 10:11 am, ADM was asked what he expected LVN C to do when she found out about the incident between CNA A and Resident #2. He said LVN C should have ensured Resident #2's safety, make sure CNA A wouldn't do it again by moving her to another hall, assess Resident #2, and call him to report the incident. ADM said he thought moving CNA A to the other hall was sufficient. He had no problems with her in the past. She was responding to him hitting her. When asked if he conducted in-services after the incident he said he did not because it was an isolated incident; if it was a rampant problem he would have in-serviced staff. He thinks it was a reaction, she wouldn't have normally hit him. She should have restrained herself, but she didn't. After the investigation he felt it was best to terminate her. ADM was asked if the facility offers staff training on how to handle residents when they become combative. ADM said during orientation they are taught to try to approach residents at the resident's level and not to be domineering. During an interview with CNA A on 10/9/20 at 10:29 am, CNA A said she didn't know why she hit Resident #2. She said he was always real combative, but she could usually work with him and provide care. She said she and another CNA were going to change him because he was wet. She said she had the draw sheet and the pad and explained what they had to do and why. She went to roll him over using the draw sheet and he got me right in the eye. I have no idea why, I popped him on the chest and said, 'That's enough!' She said it was a knee jerk reaction. She said he was the last one on their rounds. She said she has never acted like that before. CNA A said, It was probably from exhaustion catching up with me and I didn't notice it. She said, There is no excuse. She said she was not given any training at the facility on how to handle combative residents. She was never told what was on his care plan on what they were supposed to do when he rejects care.

Based on interviews and record reviews, in response to an allegation of abuse the facility failed to prevent further potential abuse or mistreatment while an investigation was in progress for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to prevent further potential abuse when CNA A was assigned a different hall and allowed to finish out her shift after she hit Resident #2 on his chest. This failure could place residents at risk of abuse, injury, fear and hopelessness. Findings include: Record review of Resident #2's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #2's quarterly MDS dated [DATE] documented Resident #2 had severe cognitive impairment and displayed verbal and physical behaviors. Record review of Resident #2's Care Plan last revised on 6/26/20 documented the following: Focus: o The resident is resistive to care refuses showers, meals and ADL assistance often. Prefers certain staff for ADL assistance, verbally and physically aggressive at times. Refuses meals, meds and getting out of bed often. Date Initiated: 04/01/2020 Revision on: 06/26/2020 Interventions/Tasks: o Allow the resident to make decisions about treatment regime, to provide sense of control. Date Initiated: 04/01/2020 o Encourage as much participation/interaction by the resident as possible during care activities. Date Initiated: 04/01/2020 o Give clear explanation of all care activities prior to an as they occur during each contact. Date Initiated: 04/01/2020 o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 04/01/2020 o Praise the resident when behavior is appropriate. Date Initiated: 04/01/2020 o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Date Initiated: 04/01/2020 Record review of the facility's Provider Investigation Report, signed by the ADM on 9-17-20, documented the following: Investigation Summary - Attached are statements from (CNA A, CNA B, and LVN C). When interviewed more closely by this administrator and DON (name removed) and extensively on Tuesday, 9/15/20, (CNA B) proved to be more descriptive of the situation even indicating that there was a slight pause as (CNA A) responded verbally to the resident after being hit and then raised her hand high in the air before the slap occurred, both of which indicated to this administrator that the hand slap was more than a kneejerk reaction as previously described. She also maintains that she had told (CNA A) to report the incident to the charge nurse or she would do so. Investigation Findings - Confirmed Provider Action Taken Post-Investigation - On 09/15/2020, administrator called (CNA A) and informed her that her employment with Edward Abraham Memorial Home was being terminated effective immediately. Statement written and signed by CNA A on 9/12/20 documented the following: An incident with (Resident #2) happened around 3:30 am. He was very combative and threating (sic) even after we explained to him more than once what (CNA B) (the other aide) and I were trying to do, which was changing him. He got more combative, then starting (sic) swinging his fists at us as we continued to clean him and do his care. At one point as we rolled (Resident #2) he hit me (CNA A) in the right eye and before I even thought I hit him in the chest with the flat of my hand Statement written and signed by LVN C on 9/12/20 documented the following: (CNA A) came to this nurse and reported that while herself and (CNA B) were changing (Resident #2), the resident hit (CNA A) in the face. (CNA A) states, out of instinct, she slapped resident on the chest. This nurse went to residents (sic) room to assess resident. Resident has a hand print on the right side of his chest. Resident seems agitated and is cursing at this time . At approximately 0354 (3:54 am), this nurse called the administrator and reported the incident to him. This nurse was advised to have both aides to write a statement as well as myself Record review of Resident #2's Weekly Skin Integrity Review documented the following: Skin Condition: Skin Intact, Bruises - Right upper chest/green in color. Dated 9/15/20 Skin Condition: Bruises - Fading bruise to right pectoral muscle. Dated 9/25/20 During an interview with LVN C on 10/8/20 at 7:24 pm, LVN C said on 9/12/20 around 3:30 am, she was getting ready to pull the morning meds on the night of the incident when CNA A came up to her and said, You need to come with me. LVN C asked CNA A why and CNA A said, We were changing (Resident #2) and he became combative and I slapped him on the chest and there is a red mark. LVN C said she went to look at him and he was clearly upset. She was able to look at his chest and could see a hand print on the right side of his chest. LVN C said she called the ADM to report it. ADM instructed her to get everyone to write a statement on what happened and to not let CNA A go back in Resident #2's room. LVN C said she didn't know she had the authority to clock CNA A out and send her home. LVN C said after CNA A finished writing her statement, there was about an hour left on the shift and CNA A left at the end of her shift. LVN C said she didn't know if CNA A was suspended because she was going on her days off then for 3 days anyway but did know she never came back to work. LVN C said she has since been told to send the alleged perpetrator of abuse or neglect home immediately after learning of an allegation of abuse or neglect. During an interview with ADM on 10/8/20 at 8:12 pm, ADM said immediately after the incident, CNA A was moved to the short hall and the other aide worked the hall where Resident #2 resided. ADM said he had never had any problems with CNA A before. Resident #2 was very hard to care for and was very difficult. ADM said, The other residents were safe because no one else hits her. I didn't think she was a risk to others. The hand print dissipated pretty quickly. She never worked another shift. ADM said what he was first told of the incident was that it was just a reflex response by CNA A after being hit by Resident #2, but during the investigation he found it may not have been a reflex after all. When he interviewed CNA B, who was in the room with CNA A and Resident #2 when the incident occurred, she gave more details than were written in her statement. CNA B said CNA A raised her hand real high back and then hit him. ADM said he didn't think that sounded like a knee jerk response, so he terminated CNA A's employment with the facility. During an interview with CNA B on 10/8/20 at 9:08 pm, CNA B said she and CNA A were doing their 2:00 am rounds. Resident #2 was the last resident on their rounds. CNA B said Resident #2 was already grumpy. She usually has a good rapport with him. He is very modest also and likes to stay covered up. He was dirty, so they had to change him. He hit CNA A in the face and CNA A told him to stop and you can't hit me. Resident #2 went to swing again and that's when CNA A hit him. CNA A first told him you can't be doing that and then pulled her hand up high and she hit him. CNA B said, She hit him hard. It was horrible. CNA B said he really started swinging then. She told CNA A to get out and she would finish cleaning him up. When she came out of Resident #2's room, she found CNA A and told her, If you don't say something to the charge nurse, I will. Once CNA A calmed down she went in the med room where LVN C was and CNA A told her she hit a resident. LVN C told them to write a statement and they slipped it under the ADM's door. CNA B said she didn't know CNA A left a hand print on Resident #2's chest until the next night when she went back to work. When she went to see Resident #2, she could see the hand print on the right side of his chest. During an interview at 8:40 am on 10/8/20 with LVN D, she said she is the one who normally does the weekly skin assessments. She said on 9/25/20 she did a skin assessment on Resident #2 and he still had a bruise to the right chest area that was fading. During an interview with the ADM on 10/9/20 at 10:11 am, ADM was asked what he expected LVN C to do when she found out about the incident between CNA A and Resident #2. He said LVN C should have ensured Resident #2's safety, make sure CNA A wouldn't do it again by moving her to another hall, assess Resident #2, and call him to report the incident. ADM said he thought moving CNA A to the other hall was sufficient. He had no problems with her in the past. She was responding to him hitting her. When asked if he conducted in-services after the incident he said he did not because it was an isolated incident; if it was a rampant problem he would have in-serviced staff. He thinks it was a reaction, she wouldn't have normally hit him. She should have restrained herself, but she didn't. After the investigation he felt it was best to terminate her. ADM was asked if the facility offers staff training on how to handle residents when they become combative. ADM said during orientation they are taught to try to approach residents at the resident's level and not to be domineering. During an interview with CNA A on 10/9/20 at 10:29 am, CNA A said she didn't know why she hit Resident #2. She said he was always real combative, but she could usually work with him and provide care. She said she and another CNA were going to change him because he was wet. She said she had the draw sheet and the pad and explained what they had to do and why. She went to roll him over using the draw sheet and he got me right in the eye. I have no idea why, I popped him on the chest and said, 'That's enough!' She said it was a knee jerk reaction. She said he was the last one on their rounds. She said she has never acted like that before. CNA A said, It was probably from exhaustion catching up with me and I didn't notice it. She said, There is no excuse. She said she was not given any training at the facility on how to handle combative residents. She was never told what was on his care plan on what they were supposed to do when he rejects care. Record review of the facility's undated Abuse Prevention Program, Polices and Procedures, documented the following: Protection of Residents During Abuse Investigations Policy Statement - Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, resident will be protected from harm by the following measures: a. Employees' accused of participating in the alleged abuse may be suspended without pay until the administrator has reviewed the findings of the investigation. Additional supervision maybe required ensuring residents safety. Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement - Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any sign and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Abuse Investigations Policy Statement - All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 7. Employees of this facility who have bee (sic) accused of resident abuse may be suspended from duty until the results of the investigation have been reviewed by the administrator. Reporting Abuse to Facility Management 7. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record.

Based on observation, interview, and record review the facility failed to implement their written policies and procedures that prohibit abuse for 1of 6 residents (Resident # 1) reviewed for abuse. 1. Staff members (CNA F, HA D) taunted and laughed at Resident #1 while providing her incontinent care, while HA C videotaped the occurrence. The resident was exposed, with her pants and briefs down. 2. This video of Resident #1 was shown to the DON, ADON, LVN C, LVN A and LVN B on [DATE]. It was not reported to the ADM until [DATE]rd, 2015. The ADM did not report this to the appropriate state agency after being informed of the video. There was no investigation conducted by the facility; no interviews of Residents or additional staff were conducted, there were no in-services conducted on abuse or neglect. 3. The facility did not protect Resident #1 from potential further abuse, by allowing ( HA C, CNA F, and HA D) to remain working on the floor and in contact with Resident #1 until the surveyor entered the facility on [DATE]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to follow their policies and procedures to protect Resident #1 from abuse, could affect all 23 residents of the facility because the ADM, DON, ADON, LVN C, 2 HA's and 1 CNA were involved in placing all residents in the facility at risk of abuse, feelings of mental anguish, anxiety, psychological harm, emotional upset, development or worsening of depression, fear of staff and retaliation, all resulting in a negative impact on their quality of life. Findings include: Review of the facility policy and Procedure on Abuse Prohibition and Prevention provided by the ADM on [DATE] and dated [DATE] stated: It is the policy of this facility that we will not tolerate any kind of abuse of residents. To further this policy the following criteria are maintained. Training: Orientation training Continuing in-service training Interventions Reporting Detection Prevention Identification of events and occurrences constituting or contributing Investigation of all allegations of abuse, neglect or mistreatment Protection of all individuals during investigations of allegations Reporting and responses Reporting of incidents Corrective/preventative actions Staff Responsible for Coordination/Implementing Abuse Prevention Program Policies and Procedures The Administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 2. The Administrator has the authority to delegate coordination and implementation of our facility's abuse program policies and procedures to other individuals within the facility these may include: a. The Director of Nurses Services b. The Quality Assurance Committee c. The Business Office Manager d. Other staff members as determined by the Administrator Protection of Residents during Investigations Policy Interpretation and Implementation 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse may be suspended without pay until the administrator has reviewed the findings of the investigation. Additional supervision maybe required ensuring resident's safety. Reporting Abuse to State Agencies and Other Entities/Individuals All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. 2. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator or his/her designee, will promptly notify the following person or agencies (verbally or written) of such incident. a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The Resident's representative (Sponsor) of record; c. The Resident's Attending Physician; and d. The Facility Medical Director. 3. Verbal/written notices to the above agencies will be made as soon as possible such incident and such notice may be submitted by telephone. Notices will include, as a minimum: a. The name of Resident b. The number of the room in which the Resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, et.); d. The date and time the alleged incident occurred; e. The name(s) of all persons involved in the alleged incident; and f. What immediate action was taken by the facility? 4. The administrator, or his/her designed, will provide the TDHS with a written report of the finding of the investigation within 5 days of the occurrence of the incident. 5. Should the findings reveal that abuse did occur; the written report to TDHS will include the corrective actions taken by the facility to prevent abuse from recurring. 6. Appropriate professional and licensing boards will be notified when an employee is found to have committed abuse. 7. Inquiries concerning the reporting of abuse to state agencies should be referred to the Administrator. Abuse Investigation Policy Interpretation and implementation 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator, director of nursing, or his/her designee, will investigate the alleged incident. 2. The person in charge of the investigation will provide a completed copy of the TDHS facility investigation report and any supporting documents relative to the alleged incident. 3. The person in charge of the investigation will as a minimum: Review the completed incident report #,[DATE]R. Review the resident's medical record to determine events leading up to the incident; Interview the person(s) reporting the incident; Interview any witnesses (residents, family members, visitors) to the incident; Interview the resident as medically appropriate Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interview: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. Findings include: Closed record review of Resident #1's medical records revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Annual MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 2 (severe impairment), and was totally dependent on two people to assist for transfer, locomotion off the unit, and bathing. Resident #1 required supervision with with one person for hygiene. Resident #1 expired on [DATE]. During a telephone interview with LVN A on [DATE] at 2:10 p.m. LVN A stated that HA C, HA D and CNA F were getting residents agitated and then would video tape them. LVN A stated Resident #1 passed away approximately one week ago. LVN A stated she was outside on a smoke break and CNA came outside and asked her if she had seen the video of Resident #1. LVN A said, No, what are you talking about? LVN A saw the video and Resident #1 was sitting on the toilet in the shower room. LVN A could see on the video she was on the commode, they were trying to change her brief. HA C was videotaping and HA D was trying to change her brief. LVN A talked with LVN B and told her about the videotaping. LVN A and LVN B then went in to tell the DON, and the ADON. The DON, ADON, LVN C, LVN B and I watched the video. A week went by and nothing was done. On Monday (LVN A could not remember the exact date) there was a note that all cell phones were to be turned in at the beginning of the shift and they could have them on breaks and at lunch. No one turned in their cell phones, the three aides claimed they had them in their cars. LVN A could not remember the exact date of the incident. During an interview with the ADM on [DATE] at 10:20 a.m. the ADM was asked if she had any problems recently with staff, specifically HA C, HA D, and CNA F. The ADM stated, They videotaped a resident (Resident #1) that was hitting them. Resident #1 had urinated in the lobby and they took her to the shower room and were putting a clean brief on her and she was hitting them and HA C videotaped this on [DATE]. It was reported by LVN B to the ADON and the DON. On the 26th the DON and ADON saw the video, they counseled all of the girls. I saw the video for the first time today, [DATE]; I was told it had been deleted. HA C is the one who videotaped. HA D and CNA F were the ones being videotaped. Resident #1 was stating stop it, get out of here. HA D is the one talking. I was made aware of this on [DATE] (the ADM corrected this to [DATE] in an additional interview on [DATE]). It was written up, but I was not made aware of this until [DATE]th which was Monday (the ADM corrected this to [DATE] during an additional interview). When asked who was the abuse coordinator? The ADM stated, I am the abuse coordinator. The ADM was asked why this was not reported to the appropriate state agency and the incident investigated; and the ADM stated, This was just not seen as abuse. HA C, HA D, and CNA F were called in and talked to. They stated Resident #1 was trying to hit. HA D and CNA F did not know they were being videotaped. HA C stated, 'I did not know I did anything wrong, we were trying to help Resident #1'. (Surveyor asked to see the video and the video was shown to surveyor on the ADM's personal cell phone). Observation of this video by the surveyor showed Resident #1 sitting on the commode with her pants and brief down. Resident #1 is seen batting with her hands at HA D and CNA F and telling them Well, get out of here. HA D and CNA C are laughing and taunting Resident #1. HA D is saying Stop it and Oh, ow in a taunting voice as she laughed. During a telephone interview with LVN B on [DATE] at 11:35 a.m. she stated, Resident #1 had a [DIAGNOSES REDACTED], she had a change in behavior. HA C, HA D, and CNA F were involved with Resident #1. HA C came out and told me they needed help. Resident #1 was in the shower room sitting on the pot. Resident #1 pointed her finger at CNA F and HA D and asked them to leave. I finished dressing Resident #1. LVN A asked if I knew they videotaped Resident #1. LVN B went to the DON, ADON and LVN C and told them about the videotaping, the ADON was making excuses for them and her daughter (CNA F is the daughter of ADON). The ADON showed me the video and the first thing that went through my mind was abuse. The ADON stated she did not want this to go to the ADM because then they could not smoke or have their cell phones. We (LVN A and LVN B) wanted them to take care of this. This happened in August. I followed the chain of command and nothing was done. I went back in and talked with the DON and told her LVN A and I thought it was abuse. The DON did go in and talk with the ADM. LVN B stated that CNA F said if LVN B hadn't raised so much hell, they would not have been written them up. No one was suspended during this time. LVN B told the DON that the ADON can't separate herself from her daughter (CNA F). During an interview with HA D on [DATE] at 11:50 a.m. HA D stated, We were asked to change Resident #1, she was in the lobby by the front doors. We took her to the shower room/bathroom on this hall. HA C and I took her in her wheelchair backwards because she wouldn't go. LVN B told us to pick up her feet and take her backwards to the commode. Me and HA C got her on the pot, CNA F came in HA C left to get a call light. Me and CNA F got Resident #1's pants off we were putting her shoes on, I leaned down and she grabbed the back of my hair, we started to laugh, me and CNA F, then she let go of my hair. HA C went and got LVN B to help. I was not aware I was being videotaped. HA C was videotaping. After we left the bathroom HA C said she videotaped this. I was not aware until she said this. I have never seen the videotape. I feel videotaping is an invasion of privacy. When asked why she did not report this, she stated it had already been reported by LVN A. During an interview with CNA F on [DATE] at 12:05 p.m. CNA F stated, I was on break and when I came back, HA C and HA D were in the shower room with Resident #1. Resident #1 was on the toilet and had her pants down ready to take off her wet clothes. I asked HA C to go get a call light and asked HA C to get the charge nurse LVN B to help because Resident 1 was being resistant to care. Resident #1 got irritated and hit HA D in the face. HA C came back in the bathroom. When Resident #1 hit HA D we laughed, it was shocking. HA D continued to have problems, she reached down to down to put Resident #1's shoes on and she grabbed HA D's hair. HA C went to walk out and LVN B walked in and Resident #1 asked HA D and I to leave. I was not aware I was being videotaped. HA C stated I got that on video to show the nurses. I didn't say anything to her. She showed me the video. I told her she needed to delete it or show it to the nurse. I told LVN A that HA C videotaped this; she laughed and didn't say anything. I'm not really sure of date, but it obviously was before Resident #1 passed away. They told us we can't use the phone down the halls, videotaping is unacceptable. The DON and ADON talked to me about this. We got written up for phone and videotaping. We were not suspended during this time. I would be upset if my family member was videotaped, very upset. I don't feel HA C did this to be abusive in any way. During an interview with HA C on [DATE] at 12:20 p.m. HA C stated, Resident #1 was wet and we were asked to change her, there was a puddle on the floor. Resident #1 was up at the front. LVN B asked for us to change her. I went to her and said, 'Resident #1, I need to change you'. The resident said no. I told LVN B she had refused. LVN B said to pull her backward, HA D held her feet as we were instructed by LVN B. We got her in the shower room on the long hall and put her on the toilet, myself and HA D. Then CNA F walked in and Resident #1 was resisting care, saying, 'No, no.' CNA F said she would try. I walked out to get a call light, when I went back in, they were trying to put her pants on and Resident #1 was swinging and hitting at them. I videotaped her hitting them to show I was not taunting her. I just wanted to show them that we were not taunting her, we asked the charge nurse to help and she would not go down the hall. Neither of the other girls, HA D and CNA F knew I was videotaping them. I told CNA F that I was going to show the nurse and I showed CNA F a little bit of the video. I know this happened on a Wednesday, not sure of the date. I did not show HA D any of the video. I showed LVN A the video, she said nothing. That same day we were called into the office, the DON and ADON were there, I apologized and told them I was wrong. They told me it was wrong to videotape. I was not suspended. I was written up and our phones are taken up at the beginning of our shift. When she was asked how she would feel if someone videotaped her on the commode, HA C stated, Not right. HA C stated, I have not videotaped anyone else in the facility. During an interview with LVN C on [DATE] at 1:40 p.m. LVN C stated, I was here the day LVN B and LVN A came in, LVN B said, 'I'm sick of CNA F videotaping Resident # 1.' LVN B was upset because HA D and CNA F were laughing and taunting Resident #1. I did see the video the same day. I felt like they were trying to get Resident #1 changed to help her, she was in the shower room on the commode. LVN C stated she could not see her face. Surveyor stated to LVN C she must have seen a different video, because her face was quite clear in the video. When asked who was in the room with her when viewing this video, she stated, I can't remember, I think the ADON was with me when I saw the video. LVN B said the videotape was bad so I wanted to see. When surveyor asked why this was not reported to the ADM, LVN C stated she was here that day in the building. LVN C did not report this to the ADM. During a telephone interview with the DON on [DATE] at 1:50 p.m. she stated, I had 2 nurses, LVN A and LVN B come into my office on [DATE]. They were upset. I was not happy about the videotape, it was not appropriate. The aides were trying to help Resident #1, pulling up her brief and pants and she made contact with them, they were giggling, but they were not trying to make it worse, it's a short video, I didn't see them trying to taunt her. Yes, they were giggling they were giggling at each other. They were surprised by Resident #1. They were trying to get things done, but Resident #1 was combative. The ADM was there on [DATE], I wanted to take care of this myself, I didn't want to run to the ADM. I can't tell you if I was told this situation would need to be reported to the ADM. We had questions about who actually took the video. HA C took the video and the other two, CNA F and HA D, did not know they were being videotaped. I wrote up the verbal warnings. They (CNA F, HA C and HA D) were not suspended, I was not aware of the need to suspend, I did not know. The ADM was told about this two days after it happened. I don't remember for sure. I did not interview any residents and there were no interviews with other aides. During an interview with the ADON on [DATE] at 2:00 p.m. ADON stated, I came in at 9:30 a.m. from the hospital on [DATE]. I checked with LVN B and she said we have a problem. The people present were myself, the DON, and LVN C. CNA F is my daughter so that is why we pulled LVN C in. LVN B stated 'I'm tired of the girls being on their phones, there is a videotape of Resident #1 and CNA F took it.' LVN B stated, 'I'm pissed.' I said I was too. LVN B stated residents were not getting their baths and aides were in the break rooms on their phones. I reminded LVN B that they had the write up forms and they went out of the office to write this up. I told the DON I feel like you need to handle this because my daughter is involved. We all three talked about it. I knew there was a video. I went to find out about the video, and they sent it to my phone; and I told them to delete it. I questioned the video because CNA F was not the one that videotaped, HA C was. We looked at the video, I don't agree with taking the video. I knew this resident well, she was combative. All three of us looked at the video (myself, the DON, and LVN C). The video showed that CNA F did not take the video. After viewing the video we brought the girls in separate, HA C, HA D, and CNA F. I asked CNA F did you take the video of Resident #1, she said no, HA C did. She said Resident #1 was hitting. CNA F stated Resident #1 had HA D by the hair. CNA F stated she did not know about the video during that time. She then stated Resident #1 asked them to leave, CNA F asked LVN B to help. I asked why HA C took the video, she stated, 'because she was hitting.' My view is I heard them laughing in the video, but I felt like they were changing her and Resident #1 got HA D by the hair. Resident #1 was on the commode. Last night ([DATE]), I sent the video to the ADM. I was thinking about it. I looked through my deleted videos and found the video. Surveyor asked the ADON; who is the abuse coordinator, she stated the ADM. Surveyor asked the ADON why she did not notify the ADM and the ADON stated, I didn't feel like I needed to inform her. After myself, the DON and LVN C saw this we didn't feel like it was abuse. I felt like LVN B was being vindictive. We initiated a cell phone policy the next morning, told the staff to keep them at the nurses station or in their cars. I didn't feel like they were taunting Resident #1. The DON wrote them up. When asked by surveyor if the ADM was in the building the day of [DATE], the ADON stated, I can't remember if she was in the building that day. I left at 3:00 p.m. LVN B went back into the office to talk with the DON. The next day [DATE] the ADM was talked to by the DON. During an interview on [DATE] at 9:25 a.m. with a FM of Resident #1, the FM stated no one had called or made them aware of any videotaping or mistreatment of [REDACTED]. FM stated he hoped this would be investigated, and hopefully would not happen to anyone else. Record review of the progressive discipline form on [DATE] signed by the DON in regard to CNA F stated, Sitting in the break room, in halls, and residents rooms on phone in excess. Leaving facility without notifying nurse. Review of the progressive discipline sheet, dated [DATE] signed by the DON regarding HA C stated: Staying in break room or at the nurses station. Stays on phone in excess. Videotaping residents on cell phone. A note at the bottom of the sheet dated [DATE] and signed by the ADM stated: Was filmed by accident and video was destroyed. Review of the progressive discipline form dated [DATE] signed by the DON regarding HA D stated: Sitting in the break room and staying on the phone in excess. Walking up and down the hallway with phone in hand. The facility ADM was notified on [DATE] at 1:15 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the ADM on [DATE] at 5:50 p.m. The Plan of Removal was accepted at 10:30 a.m. on [DATE]. The facility took the following actions to remove the IJ: Problem: Videotaping Resident #1 in a compromised situation. CNA F and HA D were taunting and laughing at Resident #1. The DON, ADON, LVN C, HA C, HA D, and CNA F were aware and of this and did not report this to the ADM. HA C did the actual videotaping. The ADM upon learning of this videotaping of Resident #1 did not report this incident to the proper authorities, did not investigate the incident, did not suspend the staff involved, and did not follow the facility's procedures on abuse and neglect. Interventions: The Administrator held an in-service for staff on recognizing and reporting abuse and neglect on [DATE]. Thirty five employees attended. The subjects that were covered were: A. What is abuse? B. What to do if you suspect abuse. C. Who can report suspected abuse? D. How and where do you report abuse? E. Residents rights involving being treated with courtesy, consideration, respect, and privacy. F. Policy regarding cell phone usage. Abuse and Resident Rights will be a continued In-Service at each monthly meeting. Abuse reporting and cell phone policy will be reviewed with each employee upon hire and 1 on 1 at each employee's annual review. Cell phone usage in patient care areas is prohibited. All cell phones are to be kept out of site while on the clock. Staff will check all cell phones into the charge nurse at the start of the shift. Phones will be placed in the medication room. Cell phones may be check out from the med room while employees are on break or at lunch. When the break or lunch is over the phone will be checked back to the charge nurse and placed in the med room. The charge nurse will do walking rounds through the shower area to ensure there are no phones being used in resident care areas. A sign in sheet has been created for Q 2 hour shower rounds; these are to be initialed by the staff conducting the rounds. Any employee found in a resident care area with a cell phone will be subject to disciplinary action up to and including termination. It is the responsibility of every employee to report suspected abuse. Reports are to be made to your supervisor, charge nurse, ADON, DON, or Abuse Coordinator/Administrator. Upon notification of suspected abuse, the supervisor, charge nurse, ADON, or DON will immediately notify the Abuse Coordinator/Administrator. If a front line staff member wishes to report an allegation of abuse directly, they may contact the Abuse Coordinator/Administrator at any time. The Abuse Coordinator will advise the staff of the appropriate action to take. If a staff member is involved in the allegation, they are to be suspended from work until the investigation is complete. After the abuse Coordinator has been notified of a suspected case, a call will be placed to the Provider Self reporting hotline to report the allegation. If the Abuse Coordinator is not available the DON will make this phone call. In the absence of the DON, the ADON will make this phone call. If the ADON is not available the charge nurse may call the hotline. The DADS form 3613-A is kept in the Abuse policy book at the nurse's station which is available at all times. The person alleging suspected abuse will make a statement with facts, times, dates, occurrences, and names of anyone involved. The 3619 will be faxed to DADS within 5 working days. If the internal investigation substantiates the allegation, appropriate disciplinary action up to termination will take place. As of Friday [DATE], the following staff has been suspended pending the investigation of abuse: DON, ADON, LVN C, HA C, HA D, and CNA F. Interviews with 10 different staff members on [DATE] from 11:40 a.m. to 1:50 p.m. revealed all had been in serviced on abuse and neglect. They all stated they would report any allegation of abuse to the ADM. They had been told that cell phones were no to be on their person and when checking with all above parties, no cell phones were present on staff. Observation of the medication room on [DATE] at 11:55 a.m. revealed a basket with cell phones on the counter. Observation of the shower sheets revealed that this was initiated on [DATE] starting at 3:00 p.m. and has been completed every two hours since that time. Interviews were conducted by the ADM on [DATE] with 7 residents in the facility asking if they had ever been abused or mistreated at the facility. Residents were also asked if they felt safe at the facility. Interviews were conducted with 21 staff members starting on [DATE] through [DATE]. In the interviews staff was asked if they had seen any abuse of residents in the facility and if they did who they would report it to. The Administrator was informed that the immediacy of the IJ was removed on [DATE] at 10:30 a.m., however the facility, remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The ADM provided census on [DATE] was 23.

Based on observation, interview and record review, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 1 of 6 Residents (Resident #1) reviewed for dignity. 1. Staff members (CNA F and HA D) taunted and laughed at Resident #1 when providing incontinent care. HA C videotaped this occurrence. Resident #1 was exposed, with her pants and brief down. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to promote care in a manner and environment that maintains and enhances dignity could affect all 23 residents of the facility resulting in feelings of mental anguish, anxiety, psychological harm, emotional upset, development or worsening of depression, and fear of staff and retaliation, all resulting in a negative impact on their quality of life. Findings include: Closed record review of Resident #1's medical records revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 expired on [DATE]. Review of the Annual MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 2 (severe impairment). Resident #1 was suffering from a neoplasm of the brain, and was totally dependent on two people to assist for transfer, locomotion off the unit, and bathing. Resident #1 required supervision with with one person for hygiene. Resident #1 expired on [DATE]. During a telephone interview with LVN A on [DATE] at 2:10 p.m. LVN A stated that HA C, HA D and CNA F were getting residents agitated and then would video tape them. LVN A stated Resident #1 passed away approximately one week ago. LVN A stated she was outside on a smoke break and CNA F came outside and asked her if she had seen the video of Resident #1. LVN A said, No, what are you talking about? LVN A saw the video and Resident #1 was sitting on the toilet in the shower room. LVN A could see on the video Resident #1 was on the commode, they were trying to change her brief. HA C was videotaping and HA D was trying to change her brief. LVN A talked with LVN B and told her about the videotaping. LVN A and LVN B then went in to tell the DON, and the ADON. The DON, ADON, LVN C, LVN B and LVN A watched the video. A week went by and nothing was done. On Monday (LVN A could not remember the exact date) there was a note that all cell phones were to be turned in at the beginning of the shift and they could have them on breaks and at lunch. No one turned in their cell phones, the three aides claimed they had them in their cars. LVN A could not remember the exact date of the incident. During an interview with the ADM on [DATE] at 10:20 a.m. the ADM was asked if she had any problems recently with staff, specifically HA C, HA D, and CNA F. The ADM stated, They videotaped a resident (Resident #1) that was hitting them. She had urinated in the lobby and they took her to the shower room and were putting a clean brief on her and she was hitting them. HA C videotaped this on [DATE]. It was reported by LVN B to the ADON and the DON on the 26th the DON and ADON saw the video, they counseled all of the girls. I saw the video for the first time today, [DATE]; I was told it had been deleted. HA C is the one who videotaped. HA D and CNA F were the ones being videotaped. Resident #1 was stating, 'Stop it, get out of here.' HA D is the one talking. I was made aware of this on [DATE] (the ADM corrected this to [DATE] in an additional interview on [DATE]). It was written up, but I was not made aware of this until [DATE]th which was Monday (the ADM corrected this to [DATE] during an additional interview). When asked who is the abuse coordinator? The ADM stated, I am the abuse coordinator. Observation of this video by the surveyor showed Resident #1 sitting on the commode with her pants and brief down. Resident #1 is seen batting with her hands at HA D and LVN F and telling them Well, get out of here. HA D and LVN C are laughing and taunting Resident #1. HA D is saying Stop it. and 'Oh ow. in a taunting voice as she laughed. During a telephone interview with LVN B on [DATE] at 11:35 a.m. she stated, Resident #1 had a [DIAGNOSES REDACTED], she had a change in behavior. HA C, HA D, and CNA F were involved with Resident #1. HA C came out and told me they needed help. Resident #1 was in the shower room sitting on the pot. Resident #1 pointed her finger at CNA F and HA D and asked them to leave. I finished dressing Resident #1. LVN A asked me if I knew they videotaped Resident #1. LVN B went to the DON, ADON and LVN C and told them about the videotaping, the ADON was making excuses for them and her daughter (CNA F is the daughter of ADON). LVN B said, the ADON showed me the video and the first thing that went through my mind was abuse. The ADON stated she did not want this to go to the ADM because then they could not smoke or have their cell phones. We (LVN A and LVN B) wanted them to take care of this. This happened in August. I followed the chain of command and nothing was done. I went back in and talked with the DON and told her LVN A and I thought it was abuse. During an interview with HA D on [DATE] at 11:50 a.m. HA D stated, We were asked to change Resident #1, she was in the lobby by the front doors. We took her to the shower room/bathroom on this hall. HA C and I took her in her wheelchair backwards because she wouldn't go. LVN B told us to pick up her feet and take her backwards to the commode. Me and HA C got her on the pot, CNA F came in HA C left to get a call light. Me and CNA F got Resident #1's pants off; we were putting her shoes on, I leaned down and she grabbed the back of my hair, we started to laugh, me and CNA F, then she let go of my hair. HA C went and got LVN B to help. I was not aware I was being videotaped. HA C was videotaping. After we left the bathroom HA C stated, 'I videotaped this.' I was not aware until she said this. I have never seen the videotape. I feel videotaping is an invasion of privacy. When asked why she did not report this, she stated it had already been reported by LVN A. During an interview with CNA F on [DATE] at 12:05 p.m. CNA F stated, I was on break and when I came back, HA C and HA D were in the shower room with Resident #1. Resident #1 was on the toilet and had her pants down ready to take off her wet clothes. I asked HA C to go get a call light and asked HA C to get the charge nurse LVN B to help because Resident 1 was being resistant to care. Resident #1 got irritated and hit HA D in the face. HA C came back in the bathroom. When Resident #1 hit HA D we laughed, it was shocking. HA D continued to have problems, she reached down to put Resident #1's shoes on and she grabbed HA D's hair. HA C went to walk out and LVN B walked in and Resident #1 asked HA D and I to leave. I was not aware I was being videotaped. HA C stated, 'I got that on video to show the nurses.' I didn't say anything to her. She showed me the video. I told her she needed to delete it or show it to the nurse. I told LVN A that HA C videotaped this; she laughed and didn't say anything. I'm not really sure of date, but it obviously was before Resident #1 passed away. They told us we can't use the phone down the halls, videotaping is unacceptable. The DON and ADON talked to me about this. We got written up for phone and videotaping. We were not suspended during this time. I would be upset if my family member was videotaped, very upset. I don't feel HA C did this to be abusive in any way. During an interview with HA C on [DATE] at 12:20 p.m. HA C stated, Resident #1 was wet and we were asked to change her, there was a puddle on the floor. Resident #1 was up at the front. LVN B asked for us to change her. I went to her and said, 'Resident #1 I need to change you,' she said no. I told LVN B so she said to pull her backward, HA D held her feet as we were instructed. We got her in the shower room on the long hall and put her on the toilet, myself and HA D. Then CNA F walked in and Resident #1 was resisting care, saying, 'No, no.' CNA F said she would try. I walked out to get a call light, when I went back in, they were trying to put her pants on and Resident #1 was swinging and hitting at them. I videotaped her hitting them to show I was not taunting her. I just wanted to show them that we were not taunting her, we asked the charge nurse to help and she would not go down the hall. Neither of the other girls, HA D and CNA F knew I was videotaping them. I told CNA F that I was going to show the nurse and I showed CNA F a little bit of the video. I know this happened on a Wednesday, not sure of the date. I did not show HA D any of the video. I showed LVN A the video, she said nothing. That same day we were called into the office, the DON and ADON were there, I apologized and told them I was wrong. They told me it was wrong to videotape. I was not suspended. I was written up and our phones are taken up at the beginning of our shift. When she was asked how she would feel if someone videotaped her on the commode, HA C stated, Not right. HA C stated, I have not videotaped anyone else in the facility. During an interview with LVN C on [DATE] at 1:40 p.m. LVN C stated, I was here the day LVN B and LVN A came in, LVN B said, 'I'm sick of CNA F videotaping Resident # 1.' LVN B was upset because HA D and CNA F were laughing and taunting Resident #1. I did see the video the same day. I felt like they were trying to get Resident #1 changed to help her, she was in the shower room on the commode. LVN C said she could not see her face. Surveyor stated to LVN C she must have seen a different video, because her face was quite clear in the video. When asked who was in the room with her when viewing this video, she stated, I can't remember, I think the ADON was with me when I saw the video. LVN B said the videotape was bad so I wanted to see. During a telephone interview with the DON on [DATE] at 1:50 p.m. she stated, I had 2 nurses, LVN A and LVN B come into my office on [DATE]. They were upset. I was not happy about the videotape, it was not appropriate. The aides were trying to help Resident #1, pulling up her brief and pants and she made contact with them, they were giggling, but they were not trying to make it worse, it's a short video, I didn't see them trying to taunt her. Yes, they were giggling they were giggling at each other. They were surprised by Resident #1. They were trying to get things done, but Resident #1 was combative. HA C took the video and the other two, CNA F and HA D, did not know they were being videotaped. During an interview with the ADON on [DATE] at 2:00 p.m. ADON stated, I came in at 9:30 a.m. from the hospital on [DATE]. I checked with LVN B and she said we have a problem. The people present were myself, the DON, LVN C. CNA F is my daughter so that is why we pulled LVN C in. LVN B stated, 'I'm tired of the girls being on their phones, there is a videotape of Resident #1 and told me CNA F took it and LVN B stated, 'I'm pissed.' I said I was too. LVN B stated residents were not getting their baths and aides were in the break rooms on their phones. I reminded LVN B that they had the write up forms and they went out of the office to write this up. I told the DON I feel like you need to handle this because my daughter is involved. We all three talked about it. I knew there was a video. I went to find out about the video,and they sent it to my phone; and I told them to delete it. I questioned the video because CNA F was not the one that videotaped, HA C was. We looked at the video, I don't agree with taking the video. I knew this resident well, she was combative. All three of us looked at the video (myself, the DON, and LVN C). The video showed that CNA F did not take the video. After viewing the video we brought the girls in separate, HA C, HA D, and CNA F. I asked CNA F did you take the video of Resident #1, she said no, HA C did. She said Resident #1 was hitting. CNA F stated Resident #1 had HA D by the hair. CNA F stated she did not know about the video during that time. She then stated Resident #1 asked them to leave, CNA F asked LVN B to help. I asked why HA C took the video, she stated, 'because she was hitting.' My view is I heard them laughing in the video, but I felt like they were changing her and Resident #1 got HA D by the hair. Resident #1 was on the commode. Last night ([DATE]), I sent the video to the ADM. I was thinking about it. I looked through my deleted videos and found the video. Record review of the progressive discipline form on [DATE] signed by the DON in regard to CNA F stated, Sitting in the break room, in halls, and residents rooms on phone in excess. Leaving facility without notifying nurse. Review of the progressive discipline sheet, dated [DATE] signed by the DON regarding HA C stated: Staying in break room or at the nurses station. Stays on phone in excess. Videotaping residents on cell phone. A note at the bottom of the sheet dated [DATE] and signed by the ADM stated: Was filmed by accident and video was destroyed. Review of the progressive discipline form dated [DATE] signed by the DON regarding HA D stated: Sitting in the break room and staying on the phone in excess. Walking up and down the hallway with phone in hand. Review of the facility policy dated [DATE] titled Procedure on Abuse Prohibition and Prevention provided by the ADM on [DATE] stated: It is the policy of this facility that we will not tolerate any kind of abuse of residents. The facility ADM was notified on [DATE] at 1:15 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the ADM on [DATE] at 5:50 p.m. The Plan of Removal was accepted at 10:30 a.m. on [DATE]. The facility took the following actions to remove the IJ: Problem: Videotaping Residents #1 in a compromised situation. CNA F and HA D were taunting and laughing at Resident #1. The DON, ADON, LVN C, CNA F, HA C, HA D were aware and of this and did not report this to the ADM. HA C did the actual videotaping. The ADM upon learning of this videotaping of Resident #1 did not report this incident to the proper authorities, did not investigate the incident, and did not follow the facility's procedures on abuse and neglect. Interventions: The Administrator held an in-service for staff on recognizing and reporting abuse and neglect on [DATE]. Thirty five employees attended. The subjects that were covered were: A. What is abuse? B. What to do if you suspect abuse. C. Who can report suspected abuse? D. How and where do you report abuse? E. Residents rights involving being treated with courtesy, consideration, respect, and privacy. F. Policy regarding cell phone usage. Abuse and Resident Rights will be a continued In-Service at each monthly meeting. Abuse reporting and cell phone policy will be reviewed with each employee upon hire and 1 on 1 at each employee's annual review. Cell phone usage in patient care areas is prohibited. All cell phones are to be kept out of site while on the clock. Staff will check all cell phones into the charge nurse at the start of the shift. Phones will be placed in the medication room. Cell phones may be check out from the med room while employees are on break or at lunch. When the break or lunch is over the phone will be checked back to the charge nurse and placed in the med room. The charge nurse will do walking rounds through the shower area to ensure there are no phones being used in resident care areas. A sign in sheet has been created for Q 2 hour shower rounds; these are to be initialed by the staff conducting the rounds. Any employee found in a resident care area with a cell phone will be subject to disciplinary action up to and including termination. It is the responsibility of every employee to report suspected abuse. Reports are to be made to your supervisor, charge nurse, ADON, DON, or Abuse Coordinator/Administrator. Upon notification of suspected abuse, the supervisor, charge nurse, ADON, or DON will immediately notify the Abuse Coordinator/Administrator. If a front line staff member wishes to report an allegation of abuse directly, they may contact the Abuse Coordinator/Administrator at any time. The Abuse Coordinator will advise the staff of the appropriate action to take. If a staff member is involved in the allegation, they are to be suspended from work until the investigation is complete. After the Abuse Coordinator has been notified of a suspected case, a call will be placed to the Provider Self reporting hotline to report the allegation. If the Abuse Coordinator is not available the DON will make this phone call. In the absence of the DON, the ADON will make this phone call. If the ADON is not available the charge nurse may call the hotline. The DADS form 3613-A is kept in the Abuse policy book at the nurse ' s station which is available at all times. The person alleging suspected abuse will make a statement with facts, times, dates, occurrences, and names of anyone involved. The 3619 will be faxed to DADS within 5 working days. If the internal investigation substantiates the allegation, appropriate disciplinary action up to termination will take place. As of Friday [DATE], the following staff has been suspended pending the investigation of abuse: DON, ADON, LVN C, CNA F, HA C, and HA D. Interviews with 10 different staff members on [DATE] from 11:40 a.m. to 1:50 p.m. revealed all had been in serviced on abuse and neglect. They all stated they would report any allegation of abuse to the ADM. They had been told that cell phones were no to be on their person and when checking with all above parties, no cell phones were present on staff. Observation of the medication room on [DATE] at 11:55 a.m. revealed a basket with cell phones on the counter. Observation of the shower monitoring sheets revealed that this was initiated on [DATE] starting at 3:00 p.m. and has been completed every two hours since that time. Interviews were conducted by the ADM on [DATE] with 7 residents in the facility asking if they had ever been abused or mistreated at the facility. Residents were also asked if they felt safe at the facility. Interviews were conducted with 21 staff members starting on [DATE] through [DATE]. In the interviews staff was asked if they had seen any abuse of residents in the facility and if they did who they would report it to. The Administrator was notified the immediacy of the IJ was lifted on [DATE] at 10:30 a.m., however, the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The ADM provided census on [DATE] was 23.

Based on observation, interview and record review, the ADM and the DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental and psychosocial well-being for 1of 6 residents (Resident # 1) reviewed for administration in that: 1. The ADM and DON failed to implement the facility's abuse and neglect policy when staff members (CNA F and HA D) taunted and laughed at Resident #1 when providing her incontinent care, while HA C videotaped the occurrence. The resident was exposed with her pants and brief down. 2. Reporting: The DON failed to report the videotaping of Resident #1 to the ADM. The DON first learned of this incident on [DATE], and did not report this to the ADM until [DATE]. The DON did not report this to the appropriate state agency. This incident was not reported to Resident #1's family member. 3. Prevention: The ADM and DON failed to identify, correct, and intervene in situations in which abuse is likely to occur. 4. Identification: The ADM and DON failed to identify events, occurrences, patterns and trends that may constitute abuse. 5. Investigation: The ADM and DON failed to fully investigate this incident. No interviews of other residents were conducted. There were no interviews of additional staff members. 6. Training: The ADM and DON failed to train staff in all 7 components of abuse. 7. Protection: The ADM and DON failed to protect residents from harm. The three staff members CNA F, HA C and HA D were involved and continued to work in the facility putting all residents of the facility at risk of abuse. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to protect Resident #1 from abuse, could affect all 23 residents of the facility because the ADM, and the DON, placed all residents in the facility at risk of abuse, feelings of mental anguish, anxiety, psychological harm, emotional upset, development or worsening of depression, fear of staff and retaliation, all resulting in a negative impact on their quality of life. Findings include: Closed record review of Resident #1's medical records revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 expired on [DATE]. Review of the Annual MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 2 (severe impairment). Resident #1 had a neoplasm of the brain and was totally dependent with two people to assist for transfer, locomotion off the unit, and bathing. During an interview with the ADM on [DATE] at 11:00 a.m. when the ADM was asked how this IJ came about, the ADM stated I think it was a communication problem. It was something that was brewing. I do think it was a problem between the ADON and her daughter; it would be difficult to supervise. I was given this as a HIPAA violation; I felt it was a HIPAA violation, not abuse. Video was not seen until [DATE]. The ADON did the investigation, she showed the DON how to investigate. During an interview with the DON on [DATE] at 2:10 p.m. she was asked how she thought this IJ came about she stated, Well, we had a situation with a video taken that was not appropriate. I tried to handle it myself and did not take it to the ADM. I was a brand new DON. The ADON didn't feel like it was abuse. I don't feel like I did anything wrong, I did this to the best of my ability at the time. During a telephone interview with LVN A on [DATE] at 2:10 p.m. LVN A stated that HA C, HA D and CNA F were getting residents agitated and then would video tape them. LVN A stated that Resident #1 passed away approximately one week ago. LVN A stated she was outside on a smoke break and CNA F came outside and asked me if I had seen the video of Resident #1. LVN A said, No, what are you talking about? LVN A saw the video and Resident #1 was sitting on the toilet in the shower room. I could see on the video she was on the commode, they were trying to change her brief, HA C was videotaping and HA D was trying to change her brief. I talked with LVN B and told her about the videotaping. LVN A and LVN B) then went in to tell the DON and also the ADON. The DON, ADON, LVN C, LVN B and I watched the video. A week went by and nothing was done. On Monday (LVN A could not remember the exact date) there was a note that all cell phones were to be turned in at the beginning of the shift and they could have them on breaks and at lunch. No one turned in their cell phones, the three aides claimed they had them in their cars. LVN A could not remember the exact date of the incident. During an interview with the ADM on [DATE] at 10:20 a.m. was asked if she had any problems recently with staff, specifically HA C, HA D, and CNA. The ADM stated They videotaped a resident (Resident #1) that was hitting them. She had urinated in the lobby and they took her to the shower room and were putting a clean brief on her and she was hitting them and HA C videotaped this on [DATE]. It was reported by LVN B to the ADON and the DON on the 26th the DON and ADON saw the video, they counseled all of the girls. I saw the video for the first time today, [DATE]; I was told it had been deleted. HA C is the one who videotaped. HA D and CNA F were the ones being videotaped. Resident #1 was stating, Stop it, get out of here. HA D is the one talking. I was made aware of this on [DATE] (the ADM corrected this to [DATE] in an additional interview on [DATE]). It was written up, but I was not made aware of this until [DATE]th which was Monday (the ADM corrected this to [DATE]) during an additional interview. When asked who is the abuse coordinator? The ADM stated I am the abuse coordinator. The ADM was asked why this was not reported to the appropriate state agency and the incident investigated and the ADM stated,This was just not seen as abuse. HA C, HA D, and CNA F were called in and talked to. They stated Resident #1 was trying to hit. HA D and CNA did not know they were being videotaped. HA C stated, I did not know I did anything wrong, we were trying to help Resident #1. (Surveyor asked to see the video and the video was shown to surveyor on the ADM's personal cell phone). Observation of this video by the surveyor showed Resident #1 sitting on the commode with her pants and brief down. Resident #1 is seen batting with her hands at HA D and CNA F and telling them Well, get out of here. HA D and CNA C are laughing and taunting Resident #1. HA D is saying Stop it and Oh, ow in a taunting voice as she laughed. During a telephone interview with LVN B on [DATE] at 11:35 a.m. she stated Resident #1 had a [DIAGNOSES REDACTED], she had a change in behavior. HA C, HA D, and CNA F were involved with Resident #1. HA C came out and told me they needed help. Resident #1 was in the shower room sitting on the pot. Resident #1 pointed her finger at CNA F and HA D and asked them to leave. I finished dressing Resident #1. LVN A stated do you know they videotaped Resident #1. I went to DON, ADON and LVN C and told them about the videotaping, the ADON was making excuses for them and her daughter (CNA F is the daughter of ADON). The ADON showed me the video and the first thing that went through my mind was abuse. The ADON stated she did not want this to go to the ADM because they could not smoke or have their cell phones. We ( LVN A and LVN B) wanted them to take care of this. This happened in August. I followed the chain of command and nothing was done. I went back in and talked with the DON and told her LVN A and I thought it was abuse. The DON did go in and talk with the ADM. LVN A stated that CNA F said if I hadn't raised so much hell, they would not have written them up. They were not suspended during this time. I told the DON that the ADON can't separate herself from her daughter (CNA F). During an interview with HA D on [DATE] at 11:50 a.m. HA D stated We were asked to change Resident #1, she was in the lobby by the front doors. We took her to the shower room/bathroom on this hall. HA C and I took her in her wheelchair backwards because she wouldn ' t go. LVN B told us to pick up her feet and take her backwards to the commode. Me and HA C got her on the pot, CNA F came in HA C left to get a call light. Me and CNA F got Resident #1's pants off we were putting her shoes on, I leaned down and she grabbed the back of my hair, we started to laugh, me and CNA, then she let go of my hair. HA C went and got LVN B to help. I was not aware I was being videotaped. HA C was videotaping. After we left the bathroom HA C stated, I videotaped this. I was not aware until she said this. I have never seen the videotape. I feel videotaping is an invasion of privacy. When asked why she did not report this, she stated it had already been reported by LVN A. During an interview with CNA F on [DATE] at 12:05 p.m. CNA F stated I was on break and when I came back, HA C and HA D were in the shower room with Resident #1. Resident #1 was on the toilet and had her pants down ready to take off her wet clothes. I asked HA C to go get a call light and asked HA C to get the charge nurse LVN B to help because Resident 1 was being resistant to care. Resident #1 got irritated and hit HA D in the face. HA C came back in the bathroom. When Resident #1 hit HA D we laughed, it was shocking. HA D continued to have problems, she reached down to down to put Resident #1's shoes on and she grabbed HA D's hair. HA C went to walk out and LVN B walked in and Resident #1 asked HA D and I to leave. I was not aware I was being videotaped. HA C stated I got that on video to show the nurse's. I didn ' t say anything to her. She showed me the video. I told her she needed to delete it or show it to the nurse. I told LVN A that HA C videotaped this; she laughed and didn't say anything. I'm not really sure of date, but it obviously was before Resident #1 passed away. They told us we can't use the phone down the halls, videotaping is unacceptable. The DON and ADON talked to me about this. We got written up for phone and videotaping. We were not suspended during this time. I would be upset if my family member was videotaped, very upset. I don't feel HA C did this to be abusive in any way. During an interview with HA C on [DATE] at 12:20 p.m. HA C stated, Resident #1 was wet and we were asked to change her, there was a puddle on the floor. Resident #1 was up at the front. LVN B asked for us to change her. I went to her and said Resident #1 we need to change you, she said no. I told LVN B so she said to pull her backward, HA D held her feet as we were instructed. We got her in the shower room on the long hall and put her on the toilet, myself and HA D. Then CNA walked in and Resident #1 was resisting care, saying, no, no. CNA said she would try. I walked out to get a call light, when I went back in, they were trying to put her pants on and Resident #1 was swinging and hitting at them. I videotaped her hitting them to show I was not taunting her. I just wanted to show them that we were not taunting her, we asked the charge nurse to help and she would not go down the hall. Neither of the other girls, HA D and CNA F knew I was videotaping them. I told CNA F that I was going to show the nurse and I showed CNA F a little bit of the video. I know this happened on a Wednesday, not sure of the date. I did not show HA D any of the video. I showed LVN A the video, she said nothing. That same day we were called into the office, the DON and ADON were there, I apologized and told them I was wrong. They told me it was wrong to videotape. I was not suspended. I was written up and our phones are taken up at the beginning of our shift. When she was asked how she would feel if someone videotaped her on the commode, HA C stated Not right. HA C stated I have not videotaped anyone else in the facility. During an interview with LVN C on [DATE] at 1:40 p.m. LVN C stated, I was here the day LVN B and LVN A came in, LVN B said, I'm sick of CNA F videotaping Resident # 1. LVN B was upset because CNA F and HA D were laughing and taunting Resident #1. I did see the video the same day. I felt like they were trying to get Resident #1 changed to help her, she was in the shower room on the commode. LVN C stated you could not see her face. Surveyor stated to MDS she must have seen a different video, because her face was quite clear in the video. When asked who was in the room with her when viewing this video, she stated, I can't remember, I think the ADON was with me when I saw the video. LVN B said the videotape was bad so I wanted to see. When surveyor asked why this was not reported to the ADM, LVN C stated she was here that day in the building. LVN C did not report this to the ADM. During a telephone interview with the DON on [DATE] at 1:50 p.m. she stated, I had 2 nurses, LVN A and LVN B come into my office on [DATE]. They were upset. I was not happy about the videotape, it was not appropriate. The aides were trying to help Resident #1, pulling up her brief and pants and she made contact with them, they were giggling but they were not trying to make it worse, it's a short video, I didn't see them trying to taunt her. Yes, they were giggling they were giggling at each other, they were surprised by Resident #1. They were trying to get things done, but Resident #1 was combative. The ADM was there on [DATE], I wanted to take care of this myself, I didn't want to run to the ADM. I can't tell you if I was told this situation would need to be reported to the ADM. We had questions about who actually took the video. HA C took the video and the other two CNA F and HA D did not know they were being videotaped. I wrote up the verbal warnings. They (CNA F, HA C and HA D) were not suspended, I was not aware of the need to suspend, I did not know. The ADM was told about this two days after it happened. I don't remember for sure. I did not interview any residents and there were no interviews with other aides. During an interview with the ADON on [DATE] at 2:00 p.m. ADON stated, I came in at 9:30 a.m. from the hospital on [DATE]. I checked with LVN B and she said we have a problem. The people present were myself, the DON, and MDS. CNA F is my daughter so that is why we pulled MDS in. LVN B stated I'm tired of the girls being on their phones, there is a videotape of Resident #1 and told me CNA F took it and LVN B stated, I'm pissed. I said I was too. LVN B stated Residents were not getting their baths and aides were in the break rooms on their phones. I reminded LVN B that they had the write up forms and they went out of the office to write this up. I told the DON I feel like you need to handle this because my daughter is involved. We all three talked about it. I knew there was a video. I went to find out about the video, they sent it to my phone, and I told them to delete it. I questioned the video because CNA F was not the one that videotaped, HA C was. We looked at the video, I don't agree with taking the video. I knew this resident well, she was combative. All three of us looked at the video (myself, the DON, and LVN C). The video showed that CNA F did not take the video. After viewing the video we brought the girls in separate, HA C, HA D, and CNA F. I asked CNA F did you take the video of Resident #1, she said no, HA C did. She said Resident #1 was hitting. CNA F stated Resident #1 had HA D by the hair. CNA F stated she did not know about the video during that time. She then stated Resident #1 asked them to leave, CNA F asked LVN B to help. I asked why HA C took the video, she stated, Because she was hitting. My view is I heard them laughing in the video, but I felt like they were changing her and Resident #1 got HA D by the hair, Resident #1 was on the commode. Last night ([DATE]), I sent the video to the ADM. I was thinking about it. I looked through my deleted videos and found the video. Surveyor asked the ADON; Who is the abuse coordinator? she stated the ADM. Surveyor asked the ADON why she did not notify the ADM and the ADON stated, I didn't feel like I needed to inform her. After myself, the DON and LVN C saw this we didn't feel like it was abuse. I felt like LVN B was being vindictive. We initiated a cell phone policy the next morning told the staff to keep them at the nurses station or in their cars. I didn't feel like they were taunting Resident #1. The DON wrote them up. When asked by surveyor if the ADM was in the building the day of [DATE], the ADON stated I can't remember if she was in the building that day. I left at 3:00 p.m. LVN B went back into the office to talk with the DON. The next day [DATE] the ADM was talked to by the DON. During a confidential interview, confidential person #1 stated no one had called or made the family aware of any videotaping or mistreatment of [REDACTED]. Confidential person #1 stated he hoped this would be investigated, and hopefully would not happen to anyone else. Record review of the progressive discipline form on [DATE] and signed by the DON in regard to CNA stated, sitting in the break room, in halls, and residents rooms on phone in excess. Leaving facility without notifying nurse. Review of the progressive discipline sheet, dated [DATE] and signed by the DON regarding HA C stated: Staying in break room or at the nurses station. Stays on phone in excess. Videotaping residents on cell phone. A note at the bottom of the sheet dated [DATE] and signed by the ADM stated: Was filmed by accident and video was destroyed. Review of the progressive discipline form dated [DATE] and signed by the DON regarding HA D stated: Sitting in the break room and staying on the phone in excess. Walking up and down the hallway with phone in hand. Review of the facility policy and Procedure on Abuse Prohibition and Prevention provided by the ADM on [DATE] and dated [DATE] stated: It is the policy of this facility that we will not tolerate any kind of abuse of residents. To further this policy the following criteria are maintained. Training: Orientation training Continuing in-service training Interventions Reporting Detection Prevention Identification of events and occurrences constituting or contributing Investigation of all allegations of abuse, neglect or mistreatment Protection of all individuals during investigations of allegations Reporting and responses Reporting of incidents Corrective/preventative actions Staff Responsible for Coordination/Implementing Abuse Prevention Program Policies and Procedures The administrator assumes the responsibility for the overall coordination and implementation of our facility ' s abuse prevention program policies and procedures. Policy Interpretation and Implementation 2. The administrator has the authority to delegate coordination and implementation of our facility ' s abuse program policies and procedures to other individuals within the facility these may include: a. The director of Nurses Services b. The quality Assurance Committee c. The Business Office Manager d. Other staff members as determined by the Administrator Protection of Residents during Investigations Policy Interpretation and Implementation 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees ' accused of participating in the alleged abuse may be suspended without pay until the administrator has reviewed the findings of the investigation. Additional supervision maybe required ensuring resident ' s safety. Reporting Abuse to State Agencies and Other Entities/Individuals All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. 2. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator or his/her designee, will promptly notify the following person or agencies (verbally or written) of such incident. a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The Resident ' s representative (Sponsor) of record; c. The Resident ' s Attending Physician; and d. The Facility Medical Director. 3. Verbal/written notices to the above agencies will be made as soon as possible such incident and such notice may be submitted by telephone. Notices will include, as a minimum: a. The name of Resident b. The number of the room in which the Resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, et.); d. The date and time the alleged incident occurred; e. The name(s) of all persons involved in the alleged incident; and f. What immediate action was taken by the facility? 4. The administrator, or his/her designed, will provide the TDHS with a written report of the finding of the investigation within 5 days of the occurrence of the incident. 5. Should the findings reveal that abuse did occur, the written report to TDHS will include the corrective actions taken by the facility to prevent abuse from recurring. 6. Appropriate professional and licensing boards will be notified when an employee is found to have committed abuse. 7. Inquiries concerning the reporting of abuse to state agencies should be referred to the Administrator. Abuse Investigation Policy Interpretation and implementation 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator, director of nursing, or his/her designee, will investigate the alleged incident. 2. The person in charge of the investigation will provide a completed copy of the TDHS facility investigation report and any supporting documents relative to the alleged incident. 3. The person in charge of the investigation will as a minimum: Review the completed incident report #,[DATE]R Review the resident ' s medical record to determine events leading up to the incident; Interview the person(s) reporting the incident; Interview any witnesses (residents, family members, visitors) to the incident; Interview the resident as medically appropriate Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interview: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. The facility ADM was notified on [DATE] at 1:15 p.m. that an IJ situation had been identified due to the above failures. The facility ' s plan of removal was provided by the ADM on [DATE] at 5:50 p.m. The Plan of Removal was accepted at 10:30 a.m. on [DATE]. The facility took the following actions to remove the IJ: Problem: Videotaping Residents #1 in a compromised situation. CNA F and HA D were taunting and laughing at Resident #1. The DON, ADON, LVN C, CNA F, HA C, HA D were aware and of this and did not report this to the ADM. HA C did the actual videotaping. The ADM upon learning of this videotaping of Resident #1 did not report this incident to the proper authorities, did not investigate the incident, and did not follow the facility ' s procedures on abuse and neglect. Interventions: The Administrator held an in-service for staff on recognizing and reporting abuse and neglect on [DATE]. Thirty five employees attended. The subjects that were covered were: A. What is abuse? B. What to do if you suspect abuse. C. Who can report suspected abuse? D. How and where do you report abuse? E. Residents rights involving being treated with courtesy, consideration, respect, and privacy. F. Policy regarding cell phone usage. Abuse and Resident Rights will be a continued In-Service at each monthly meeting. Abuse reporting and cell phone policy will be reviewed with each employee upon hire and 1 on 1 at each employee ' s annual review. Cell phone usage in patient care areas is prohibited. All cell phones are to be kept out of site while on the clock. Staff will check all cell phones into the charge nurse at the start of the shift. Phones will be placed in the medication room. Cell phones may be check out from the med room while employees are on break or at lunch. When the break or lunch is over the phone will be checked back to the charge nurse and placed in the med room. The charge nurse will do walking rounds through the shower area to ensure there are no phones being used in resident care areas. A sign in sheet has been created for Q 2 hour shower rounds; these are to be initialed by the staff conducting the rounds. Any employee found in a resident care area with a cell phone will be subject to disciplinary action up to and including termination. It is the responsibility of every employee to report suspected abuse. Reports are to be made to your supervisor, charge nurse, ADON, DON, or Abuse Coordinator/Administrator. Upon notification of suspected abuse, the supervisor, charge nurse, ADON, or Don will immediately notify the Abuse Coordinator/Administrator. If a front line staff member wishes to report an allegation of abuse directly, they may contact the Abuse Coordinator/Administrator at any time. The Abuse Coordinator will advise the staff of the appropriate action to take. If a staff member is involved in the allegation, they are to be suspended from work until the investigation is complete. After the Abuse Coordinator has been notified of a suspected case, a call will be placed to the Provider Self reporting hotline to report the allegation. If the Abuse Coordinator is not available the DON will make this phone call. In the absence of the DON, the ADON will make this phone call. If the ADON is not available the charge nurse may call the hotline. The DADS form 3613-A is kept in the Abuse policy book at the nurse ' s station which is available at all times. The person alleging suspected abuse will make a statement with facts, times, dates, occurrences, and names of anyone involved. The 3619 will be faxed to DADS within 5 working days. If the internal investigation substantiates the allegation, appropriate disciplinary action up to termination will take place. As of Friday [DATE], the following staff has been suspended pending the investigation of abuse: DON, ADON, LVN C , HA C, CNA F, and HA D. Interviews with 10 different staff members on [DATE] from 11:40 a.m. to 1:50 p.m. revealed all had been in serviced on abuse and neglect. They all stated they would report any allegation of abuse to the ADM. They had been told that cell phones were no to be on their person and when checking with all above parties, no cell phones were present on staff. Observation of the medication room on [DATE] at 11:55 a.m. revealed a basket with cell phones on the counter. Observation of the shower sheets revealed that this was initiated on [DATE] starting at 3:00 p.m. and has been completed every two hours since that time. Interviews were conducted by the ADM on [DATE] with 7 residents in the facility asking if they had ever been abused or mistreated at the facility. Residents were also asked if they felt safe at the facility. Interviews were conducted with 21 staff members starting on [DATE] through [DATE]. In the interviews staff was asked if they had seen any abuse of residents in the facility and if they did who they would report it to. The Administrator was informed that the immediacy of the IJ was removed on [DATE] at 10:30 a.m., however the facility, remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The ADM provided census on [DATE] was 23.

Based on observation, interview, and record review the facility failed to ensure that each resident is free from verbal, physical, and mental abuse for 1 of 6 Residents (Resident #1) reviewed for abuse. 1. Staff members (CNA F and HA D) taunted and laughed at Resident #1 when providing incontinent care. HA C videotaped this occurrence. Resident #1 was exposed, with her pants and brief down. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to protect Resident #1 from abuse, could place all 23 residents of the facility at risk of abuse, feelings of mental anguish, anxiety, psychological harm, emotional upset, development or worsening of depression, and fear of staff and retaliation, all resulting in a negative impact on their quality of life. Findings include: Closed record review of Resident #1's medical records revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 expired on [DATE]. Review of the Annual MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 2 (severe impairment). Resident #1 was suffering from a neoplasm of the brain, and was totally dependent on two people to assist for transfer, locomotion off the unit, and bathing. Resident #1 required supervision with with one person for hygiene. During a telephone interview with LVN A on [DATE] at 2:10 p.m. LVN A stated that HA C, HA D and CNA F were getting residents agitated and then would video tape them. LVN A stated Resident #1 passed away approximately one week ago. LVN A stated she was outside on a smoke break and CNA F came outside and asked her if she had seen the video of Resident #1. LVN A said, No, what are you talking about? LVN A saw the video and Resident #1 was sitting on the toilet in the shower room. LVN A could see on the video Resident #1 was on the commode, they were trying to change her brief. HA C was videotaping and HA D was trying to change her brief. LVN A talked with LVN B and told her about the videotaping. LVN A and LVN B then went in to tell the DON, and the ADON. The DON, ADON, LVN C, LVN B and LVN A watched the video. A week went by and nothing was done. On Monday (LVN A could not remember the exact date) there was a note that all cell phones were to be turned in at the beginning of the shift and they could have them on breaks and at lunch. No one turned in their cell phones, the three aides claimed they had them in their cars. LVN A could not remember the exact date of the incident. During an interview with the ADM on [DATE] at 10:20 a.m. the ADM was asked if she had any problems recently with staff, specifically HA C, HA D, and CNA F. The ADM stated, They videotaped a resident (Resident #1) that was hitting them. She had urinated in the lobby and they took her to the shower room and were putting a clean brief on her and she was hitting them. HA C videotaped this on [DATE]. It was reported by LVN B to the ADON and the DON on the 26th the DON and ADON saw the video, they counseled all of the girls. I saw the video for the first time today, [DATE]; I was told it had been deleted. HA C is the one who videotaped. HA D and CNA F were the ones being videotaped. Resident #1 was stating, 'Stop it, get out of here.' HA D is the one talking. I was made aware of this on [DATE] (the ADM corrected this to [DATE] in an additional interview on [DATE]). It was written up, but I was not made aware of this until [DATE]th which was Monday (the ADM corrected this to [DATE] during an additional interview). When asked who is the abuse coordinator? The ADM stated, I am the abuse coordinator. Observation of this video by the surveyor showed Resident #1 sitting on the commode with her pants and brief down. Resident #1 is seen batting with her hands at HA D and CNA F and telling them Well, get out of here. HA D and CNA C are laughing and taunting Resident #1. HA D is saying Stop it and Oh, ow in a taunting voice as she laughed. During a telephone interview with LVN B on [DATE] at 11:35 a.m. she stated, Resident #1 had a [DIAGNOSES REDACTED], she had a change in behavior. HA C, HA D, and CNA F were involved with Resident #1. HA C came out and told me they needed help. Resident #1 was in the shower room sitting on the pot. Resident #1 pointed her finger at CNA F and HA D and asked them to leave. I finished dressing Resident #1. LVN A asked me if I knew they videotaped Resident #1. LVN B went to the DON, ADON and LVN C and told them about the videotaping, the ADON was making excuses for them and her daughter (CNA F is the daughter of ADON). LVN B said, the ADON showed me the video and the first thing that went through my mind was abuse. The ADON stated she did not want this to go to the ADM because then they could not smoke or have their cell phones. We (LVN A and LVN B) wanted them to take care of this. This happened in August. I followed the chain of command and nothing was done. I went back in and talked with the DON and told her LVN A and I thought it was abuse. During an interview with HA D on [DATE] at 11:50 a.m. HA D stated, We were asked to change Resident #1, she was in the lobby by the front doors. We took her to the shower room/bathroom on this hall. HA C and I took her in her wheelchair backwards because she wouldn't go. LVN B told us to pick up her feet and take her backwards to the commode. Me and HA C got her on the pot, CNA F came in HA C left to get a call light. Me and CNA F got Resident #1's pants off; we were putting her shoes on, I leaned down and she grabbed the back of my hair, we started to laugh, me and CNA F, then she let go of my hair. HA C went and got LVN B to help. I was not aware I was being videotaped. HA C was videotaping. After we left the bathroom HA C stated, 'I videotaped this.' I was not aware until she said this. I have never seen the videotape. I feel videotaping is an invasion of privacy. During an interview with CNA F on [DATE] at 12:05 p.m. CNA F stated, I was on break and when I came back, HA C and HA D were in the shower room with Resident #1. Resident #1 was on the toilet and had her pants down ready to take off her wet clothes. I asked HA C to go get a call light and asked HA C to get the charge nurse LVN B to help because Resident 1 was being resistant to care. Resident #1 got irritated and hit HA D in the face. HA C came back in the bathroom. When Resident #1 hit HA D we laughed, it was shocking. HA D continued to have problems, she reached down to put Resident #1's shoes on and she grabbed HA D's hair. HA C went to walk out and LVN B walked in and Resident #1 asked HA D and I to leave. I was not aware I was being videotaped. HA C stated, 'I got that on video to show the nurses.' I didn't say anything to her. She showed me the video. I told her she needed to delete it or show it to the nurse. I told LVN A that HA C videotaped this; she laughed and didn't say anything. I'm not really sure of date, but it obviously was before Resident #1 passed away. They told us we can't use the phone down the halls, videotaping is unacceptable. The DON and ADON talked to me about this. We got written up for phone and videotaping. We were not suspended during this time. I would be upset if my family member was videotaped, very upset. I don't feel HA C did this to be abusive in any way. During an interview with HA C on [DATE] at 12:20 p.m. HA C stated, Resident #1 was wet and we were asked to change her, there was a puddle on the floor. Resident #1 was up at the front. LVN B asked for us to change her. I went to her and said, 'Resident #1 I need to change you,' she said no. I told LVN B so she said to pull her backward, HA D held her feet as we were instructed. We got her in the shower room on the long hall and put her on the toilet, myself and HA D. Then CNA F walked in and Resident #1 was resisting care, saying, 'No, no.' CNA F said she would try. I walked out to get a call light, when I went back in, they were trying to put her pants on and Resident #1 was swinging and hitting at them. I videotaped her hitting them to show I was not taunting her. I just wanted to show them that we were not taunting her, we asked the charge nurse to help and she would not go down the hall. Neither of the other girls, HA D and CNA F knew I was videotaping them. I told CNA F that I was going to show the nurse and I showed CNA F a little bit of the video. I know this happened on a Wednesday, not sure of the date. I did not show HA D any of the video. I showed LVN A the video, she said nothing. That same day we were called into the office, the DON and ADON were there, I apologized and told them I was wrong. They told me it was wrong to videotape. I was not suspended. I was written up and our phones are taken up at the beginning of our shift. When she was asked how she would feel if someone videotaped her on the commode, HA C stated, Not right. HA C stated, I have not videotaped anyone else in the facility. During an interview with LVN C on [DATE] at 1:40 p.m. LVN C stated, I was here the day LVN B and LVN A came in, LVN B said, 'I'm sick of CNA F videotaping Resident # 1.' LVN B was upset because HA D and CNA F were laughing and taunting Resident #1. I did see the video the same day. I felt like they were trying to get Resident #1 changed to help her, she was in the shower room on the commode. LVN C said she could not see her face. Surveyor stated to LVN C she must have seen a different video, because her face was quite clear in the video. When asked who was in the room with her when viewing this video, she stated, I can't remember, I think the ADON was with me when I saw the video. LVN B said the videotape was bad so I wanted to see. During a telephone interview with the DON on [DATE] at 1:50 p.m. she stated, I had 2 nurses, LVN A and LVN B come into my office on [DATE]. They were upset. I was not happy about the videotape, it was not appropriate. The aides were trying to help Resident #1, pulling up her brief and pants and she made contact with them, they were giggling, but they were not trying to make it worse, it's a short video, I didn't see them trying to taunt her. Yes, they were giggling they were giggling at each other. They were surprised by Resident #1. They were trying to get things done, but Resident #1 was combative. HA C took the video and the other two, CNA F and HA D, did not know they were being videotaped. During an interview with the ADON on [DATE] at 2:00 p.m. ADON stated, I came in at 9:30 a.m. from the hospital on [DATE]. I checked with LVN B and she said we have a problem. The people present were myself, the DON, LVN C. CNA F is my daughter so that is why we pulled LVN C in. LVN B stated, 'I'm tired of the girls being on their phones, there is a videotape of Resident #1 and told me CNA F took it and LVN B stated, 'I'm pissed.' I said I was too. LVN B stated residents were not getting their baths and aides were in the break rooms on their phones. I reminded LVN B that they had the write up forms and they went out of the office to write this up. I told the DON I feel like you need to handle this because my daughter is involved. We all three talked about it. I knew there was a video. I went to find out about the video, and they sent it to my phone; and I told them to delete it. I questioned the video because CNA F was not the one that videotaped, HA C was. We looked at the video, I don't agree with taking the video. I knew this resident well, she was combative. All three of us looked at the video (myself, the DON, and LVN C). The video showed that CNA F did not take the video. After viewing the video we brought the girls in separate, HA C, HA D, and CNA F. I asked CNA F did you take the video of Resident #1, she said no, HA C did. She said Resident #1 was hitting. CNA F stated Resident #1 had HA D by the hair. CNA F stated she did not know about the video during that time. She then stated Resident #1 asked them to leave, CNA F asked LVN B to help. I asked why HA C took the video, she stated, 'because she was hitting.' My view is I heard them laughing in the video, but I felt like they were changing her and Resident #1 got HA D by the hair. Resident #1 was on the commode. Last night ([DATE]), I sent the video to the ADM. I was thinking about it. I looked through my deleted videos and found the video. Record review of the progressive discipline form on [DATE] signed by the DON in regard to CNA F stated, Sitting in the break room, in halls, and residents rooms on phone in excess. Leaving facility without notifying nurse. Review of the progressive discipline sheet, dated [DATE] signed by the DON regarding HA C stated: Staying in break room or at the nurses station. Stays on phone in excess. Videotaping residents on cell phone. A note at the bottom of the sheet dated [DATE] and signed by the ADM stated: Was filmed by accident and video was destroyed. Review of the progressive discipline form dated [DATE] signed by the DON regarding HA D stated: Sitting in the break room and staying on the phone in excess. Walking up and down the hallway with phone in hand. Review of the facility policy dated [DATE] titled Procedure on Abuse Prohibition and Prevention provided by the ADM on [DATE] stated: It is the policy of this facility that we will not tolerate any kind of abuse of residents. To further this policy the following criteria are maintained. Training: Orientation training Continuing in-service training Interventions Reporting Detection Prevention Identification of events and occurrences constituting or contributing Investigation of all allegations of abuse, neglect or mistreatment Protection of all individuals during investigations of allegations Reporting and responses Reporting of incidents Corrective/preventative actions Staff Responsible for Coordination/Implementing Abuse Prevention Program Policies and Procedures The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 2. The administrator has the authority to delegate coordination and implementation of our facility ' s abuse program policies and procedures to other individuals within the facility these may include: a. The director of Nurses Services b. The quality Assurance Committee c. The Business Office Manager d. Other staff members as determined by the Administrator The facility ADM was notified on [DATE] at 1:15 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the ADM on [DATE] at 5:50 p.m. The Plan of Removal was accepted at 10:30 a.m. on [DATE]. The facility took the following actions to remove the IJ: Problem: Videotaping Residents #1 in a compromised situation. CNA F and HA D were taunting and laughing at Resident #1. The DON, ADON, LVN C, CNA F, HA C, HA D were aware and of this and did not report this to the ADM. HA C did the actual videotaping. The ADM upon learning of this videotaping of Resident #1 did not report this incident to the proper authorities, did not investigate the incident, and did not follow the facility's procedures on abuse and neglect. Interventions: The Administrator held an in-service for staff on recognizing and reporting abuse and neglect on [DATE]. Thirty five employees attended. The subjects that were covered were: A. What is abuse? B. What to do if you suspect abuse. C. Who can report suspected abuse? D. How and where do you report abuse? E. Residents rights involving being treated with courtesy, consideration, respect, and privacy. F. Policy regarding cell phone usage. Abuse and Resident Rights will be a continued In-Service at each monthly meeting. Abuse reporting and cell phone policy will be reviewed with each employee upon hire and 1 on 1 at each employee's annual review. Cell phone usage in patient care areas is prohibited. All cell phones are to be kept out of site while on the clock. Staff will check all cell phones into the charge nurse at the start of the shift. Phones will be placed in the medication room. Cell phones may be check out from the med room while employees are on break or at lunch. When the break or lunch is over the phone will be checked back to the charge nurse and placed in the med room. The charge nurse will do walking rounds through the shower area to ensure there are no phones being used in resident care areas. A sign in sheet has been created for Q 2 hour shower rounds; these are to be initialed by the staff conducting the rounds. Any employee found in a resident care area with a cell phone will be subject to disciplinary action up to and including termination. It is the responsibility of every employee to report suspected abuse. Reports are to be made to your supervisor, charge nurse, ADON, DON, or Abuse Coordinator/Administrator. Upon notification of suspected abuse, the supervisor, charge nurse, ADON, or DON will immediately notify the Abuse Coordinator/Administrator. If a front line staff member wishes to report an allegation of abuse directly, they may contact the Abuse Coordinator/Administrator at any time. The Abuse Coordinator will advise the staff of the appropriate action to take. If a staff member is involved in the allegation, they are to be suspended from work until the investigation is complete. After the Abuse Coordinator has been notified of a suspected case, a call will be placed to the Provider Self reporting hotline to report the allegation. If the Abuse Coordinator is not available the DON will make this phone call. In the absence of the DON, the ADON will make this phone call. If the ADON is not available the charge nurse may call the hotline. The DADS form 3613-A is kept in the Abuse policy book at the nurse's station which is available at all times. The person alleging suspected abuse will make a statement with facts, times, dates, occurrences, and names of anyone involved. The 3619 will be faxed to DADS within 5 working days. If the internal investigation substantiates the allegation, appropriate disciplinary action up to termination will take place. As of Friday [DATE], the following staff has been suspended pending the investigation of abuse: DON, ADON, LVN C, CNA F, HA C, and HA D. Interviews with 10 different staff members on [DATE] from 11:40 a.m. to 1:50 p.m. revealed all had been inserviced on abuse and neglect. They all stated they would report any allegation of abuse to the ADM. They had been told that cell phones were not to be on their person and when checking with all above parties, no cell phones were present on staff. Observation of the medication room on [DATE] at 11:55 a.m. revealed a basket with cell phones on the counter. Observation of the shower monitoring sheets revealed that this was initiated on [DATE] starting at 3:00 p.m. and has been completed every two hours since that time. Interviews were conducted by the ADM on [DATE] with 7 residents in the facility asking if they had ever been abused or mistreated at the facility. Residents were also asked if they felt safe at the facility. Interviews were conducted with 21 staff members starting on [DATE] through [DATE]. In the interviews staff was asked if they had seen any abuse of residents in the facility and if they did who they would report it to. The Administrator was informed that the immediacy of the IJ was removed on [DATE] at 10:30 a.m., however the facility, remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The ADM provided census on [DATE] was 23.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving mistreatment, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with State laws through established procedures and failed to investigate and prevent further potential abuse for 1 of 6 residents (Resident #6) reviewed for reporting of suspected cases of abuse. 1. Staff members (CNA F, HA D) taunted and laughed at Resident #1 while providing her incontinent care, while HA C videotaped the occurrence. The resident was exposed, with her pants and briefs down. 2. This video of Resident #1 was shown to the DON, ADON, LVN C, LVN A and LVN B on [DATE]. It was not reported to the ADM until [DATE]rd, 2015. The ADM did not report this to the appropriate state agency after being informed of the video. There was no investigation conducted by the facility; no interviews of Residents or additional staff were conducted, there were no in-services conducted on abuse or neglect. 3. The facility did not protect Resident #1 from potential further abuse, by allowing ( HA C, CNA F,and HA D) to remain working on the floor and in contact with Resident #1 until the surveyor entered the facility on [DATE]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to report a suspected case of abuse for Resident #1, could affect all 23 residents of the facility, placing all residents in the facility at risk of abuse, feelings of mental anguish, anxiety, psychological harm, emotional upset, development or worsening of depression, and fear of staff and retaliation, all resulting in a negative impact on their quality of life. Findings include: Closed record review of Resident #1's medical records revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 expired on [DATE]. Review of the Annual MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 2 (severe impairment). Resident #1 had a malignant neoplasm of the brain, and was totally dependent on two people to assist for transfer, locomotion off the unit, and bathing. Resident #1 required supervision with with one person for hygiene. During a telephone interview with LVN A on [DATE] at 2:10 p.m. LVN A stated that HA C, HA D and CNA F were getting residents agitated and then would video tape them. LVN A stated. Resident #1 passed away approximately one week ago. LVN A stated she was outside on a smoke break and CNA F came outside and asked if I had seen the video of Resident #1. LVN A said, No, what are you talking about? LVN A saw the video and Resident #1 was sitting on the toilet in the shower room. I could see on the video she was on the commode, they were trying to change her brief. HA C was videotaping and HA D was trying to change her brief. I talked with LVN B and told her about the videotaping. We then went in to tell the DON, and the ADON. The DON, ADON, LVN C, LVN B and I watched the video. A week went by and nothing was done. On Monday (LVN A could not remember the exact date) there was a note that all cell phones were to be turned in at the beginning of the shift and they could have them on breaks and at lunch. No one turned in their cell phones, the three aides claimed they had them in their cars. LVN A could not remember the exact date of the incident. During an interview with the ADM on [DATE] at 10:20 a.m. the ADM was asked if she had any problems recently with staff, specifically HA C, HA D, and CNA. The ADM stated, They videotaped a resident (Resident #1) that was hitting them. She had urinated in the lobby and they took her to the shower room and were putting a clean brief on her and she was hitting them and HA C videotaped this on [DATE]. It was reported by LVN B to the ADON and the DON on [DATE] and the DON and ADON saw the video, they counseled all of the girls. I saw the video for the first time today, [DATE]; I was told it had been deleted. HA C is the one who videotaped. HA D and CNA F were the ones being videotaped. Resident #1 was stating,Stop it, get out of here. HA D is the one talking. I was made aware of this on [DATE] (the ADM corrected this to [DATE] in an additional interview on [DATE]). It was written up, but I was not made aware of this until [DATE]th which was Monday. (The ADM corrected this to [DATE]) during an additional interview. When asked who is the abuse coordinator? The ADM stated,I am the abuse coordinator. The ADM was asked why this was not reported to the appropriate state agency and the incident investigated; and the ADM stated, This was just not seen as abuse. HA C, HA D, and CNA F were called in and talked to. They stated Resident #1 was trying to hit. HA D and CNA F did not know they were being videotaped. HA C stated,I did not know I did anything wrong, we were trying to help Resident #1. (Surveyor asked to see the video and the video was shown to surveyor on the ADM's personal cell phone). Observation of this video by the surveyor showed Resident #1 sitting on the commode with her pants and brief down. Resident #1 is seen batting with her hands at HA D and CNA F and telling them Well, get out of here. HA D and CNA C are laughing and taunting Resident #1. HA D is saying Stop it and Oh, ow in a taunting voice as she laughed. During a telephone interview with LVN B on [DATE] at 11:35 a.m. she stated, Resident #1 had a [DIAGNOSES REDACTED], she had a change in behavior. HA C, HA D, and CNA F were involved with Resident #1. HA C came out and told me they needed help. Resident #1 was in the shower room sitting on the pot. Resident #1 pointed her finger at CNA F and HA D and asked them to leave. I finished dressing Resident #1. LVN A stated do you know they videotaped Resident #1. I went to the DON, ADON and LVN C and told them about the videotaping, the ADON was making excuses for them and her daughter (CNA is the daughter of ADON). The ADON showed me the video and the first thing that went through my mind was abuse. The ADON stated she did not want this to go to the ADM because then they could not smoke or have their cell phones. We (LVN A and LVN B) wanted them to take care of this. This happened in August. I followed the chain of command and nothing was done. I went back in and talked with the DON and told her LVN A and I thought it was abuse. The DON did go in and talk with the ADM. LVN A stated that CNA F said if I hadn't raised so much hell, they would not have written them up. They were not suspended during this time. I told the DON that the ADON can't separate herself from her daughter (CNA F). During an interview with HA D on [DATE] at 11:50 a.m. HA D stated, We were asked to change Resident #1, she was in the lobby by the front doors. We took her to the shower room/bathroom on this hall. HA C and I took her in her wheelchair backwards because she wouldn't go. LVN B told us to pick up her feet and take her backwards to the commode. Me and HA C got her on the pot, CNA F came in and HA C left to get a call light. Me and CNA got Resident #1's pants off we were putting her shoes on, I leaned down and she grabbed the back of my hair, we started to laugh, me and CNA F, then she let go of my hair. HA C went and got LVN B to help. I was not aware I was being videotaped. HA C was videotaping. After we left the bathroom HA C stated, 'I videotaped this.' I was not aware until she said this. I have never seen the videotape. I feel videotaping is an invasion of privacy. When asked why she did not report this, she stated it had already been reported by LVN A. During an interview with CNA F on [DATE] at 12:05 p.m. CNA F stated, I was on break and when I came back, HA C and HA D were in the shower room with Resident #1. Resident #1 was on the toilet and had her pants down ready to take off her wet clothes. I asked HA C to go get a call light and asked HA C to get the charge nurse LVN B to help because Resident 1 was being resistant to care. Resident #1 got irritated and hit HA D in the face. HA C came back in the bathroom. When Resident #1 hit HA D we laughed, it was shocking. HA D continued to have problems, she reached down to down to put Resident #1's shoes on and she grabbed HA D's hair. HA C went to walk out and LVN B walked in and Resident #1 asked HA D and I to leave. I was not aware I was being videotaped. HA C stated I got that on video to show the nurses. I didn't say anything to her. She showed me the video. I told her she needed to delete it or show it to the nurse. I told LVN A that HA C videotaped this; she laughed and didn't say anything. I'm not really sure of date, but it obviously was before Resident #1 passed away. They told us we can't use the phone down the halls, videotaping is unacceptable. The DON and ADON talked to me about this. We got written up for phone and videotaping. We were not suspended during this time. I would be upset if my family member was videotaped, very upset. I don't feel HA C did this to be abusive in any way. During an interview with HA C on [DATE] at 12:20 p.m. HA C stated, Resident #1 was wet and we were asked to change her, there was a puddle on the floor. Resident #1 was up at the front. LVN B asked for us to change her. I went to her and said, 'Resident #1 I need to change you' , she said no. I told LVN B so she said to pull her backward, HA D held her feet as we were instructed. We got her in the shower room on the long hall and put her on the toilet, myself and HA D. Then CNA F walked in and Resident #1 was resisting care, saying, 'No, no.' CNA F said she would try. I walked out to get a call light, when I went back in, they were trying to put her pants on and Resident #1 was swinging and hitting at them. I videotaped her hitting them to show I was not taunting her. I just wanted to show them that we were not taunting her, we asked the charge nurse to help and she would not go down the hall. Neither of the other girls, HA D and CNA F knew I was videotaping them. I told CNA F that I was going to show the nurse and I showed CNA F a little bit of the video. I know this happened on a Wednesday, not sure of the date. I did not show HA D any of the video. I showed LVN A the video, she said nothing. That same day we were called into the office, the DON and ADON were there, I apologized and told them I was wrong. They told me it was wrong to videotape. I was not suspended. I was written up and our phones are taken up at the beginning of our shift. When she was asked how she would feel if someone videotaped her on the commode, HA C stated Not right. HA C stated I have not videotaped anyone else in the facility. During an interview with LVN C on [DATE] at 1:40 p.m. LVN C stated, I was here the day LVN B and LVN A came in, LVN B said, 'I'm sick of CNA F videotaping Resident # 1.' LVN B was upset because HA D and CNA F were laughing and taunting Resident #1. I did see the video the same day. I felt like they were trying to get Resident #1 changed to help her, she was in the shower room on the commode. LVN C stated she could not see her face. Surveyor stated to LVN C she must have seen a different video, because her face was quite clear in the video. When asked who was in the room with her when viewing this video, she stated, I can't remember, I think the ADON was with me when I saw the video. LVN B said the videotape was bad so I wanted to see. When surveyor asked why this was not reported to the ADM, LVN C stated she was here that day in the building. LVN C did not report this to the ADM. During a telephone interview with the DON on [DATE] at 1:50 p.m. she stated, I had 2 nurses, LVN A and LVN B come into my office on [DATE]. They were upset. I was not happy about the videotape, it was not appropriate. The aides were trying to help Resident #1, pulling up her brief and pants and she made contact with them, they were giggling, but they were not trying to make it worse, it's a short video, I didn't see them trying to taunt her. Yes, they were giggling they were giggling at each other. They were surprised by Resident #1. They were trying to get things done, but Resident #1 was combative. The ADM was there on [DATE], I wanted to take care of this myself, I didn't want to run to the ADM. I can't tell you if I was told this situation would need to be reported to the ADM. We had questions about who actually took the video. HA C took the video and the other two, CNA F and HA D did not know they were being videotaped. I wrote up the verbal warnings. They (CNA F, HA C and HA D) were not suspended, I was not aware of the need to suspend, I did not know. The ADM was told about this two days after it happened. I don't remember for sure. I did not interview any residents and there were no interviews with other aides. During an interview with the ADON on [DATE] at 2:00 p.m. ADON stated, I came in at 9:30 a.m. from the hospital on [DATE]. I checked with LVN B and she said we have a problem. The people present were myself, the DON, and LVN C. CNA F is my daughter so that is why we pulled LVN C in. LVN B stated 'I'm tired of the girls being on their phones, there is a videotape of Resident #1' and told me CNA F took it and LVN B stated, 'I'm pissed.' I said I was too. LVN B stated residents were not getting their baths and aides were in the break rooms on their phones. I reminded LVN B that they had the write up forms and they went out of the office to write this up. I told the DON I feel like you need to handle this because my daughter is involved. We all three talked about it. I knew there was a video. I went to find out about the video,and they sent it to my phone; and I told them to delete it. I questioned the video because CNA F was not the one that videotaped, HA C was. We looked at the video, I don't agree with taking the video. I knew this resident well, she was combative. All three of us looked at the video (myself, the DON, and LVN C). The video showed that CNA F did not take the video. After viewing the video we brought the girls in separate, HA C, HA D, and CNA F. I asked CNA F did you take the video of Resident #1, she said no, HA C did. She said Resident #1 was hitting. CNA F stated Resident #1 had HA D by the hair. CNA F stated she did not know about the video during that time. She then stated Resident #1 asked them to leave, CNA F asked LVN B to help. I asked why HA C took the video, she stated, 'because she was hitting.' My view is I heard them laughing in the video, but I felt like they were changing her and Resident #1 got HA D by the hair. Resident #1 was on the commode. Last night ([DATE]), I sent the video to the ADM. I was thinking about it. I looked through my deleted videos and found the video. Surveyor asked the ADON; who is the abuse coordinator, she stated the ADM. Surveyor asked the ADON why she did not notify the ADM and the ADON stated, I didn't feel like I needed to inform her. After myself, the DON and LVN C saw this we didn't feel like it was abuse. I felt like LVN B was being vindictive. We initiated a cell phone policy the next morning, told the staff to keep them at the nurses station or in their cars. I didn't feel like they were taunting Resident #1. The DON wrote them up. When asked by surveyor if the ADM was in the building the day of [DATE], the ADON stated, I can't remember if she was in the building that day. I left at 3:00 p.m. LVN B went back into the office to talk with the DON. The next day [DATE] the ADM was talked to by the DON. During a confidential interview, confidential person #1 stated no one had called or made the family aware of any videotaping or mistreatment of [REDACTED]. Confidential person #1 stated he hoped this would be investigated, and hopefully would not happen to anyone else. Record review of the progressive discipline form on [DATE] and signed by the DON in regard to CNA stated, sitting in the break room, in halls, and residents rooms on phone in excess. Leaving facility without notifying nurse. Review of the progressive discipline sheet, dated [DATE] and signed by the DON regarding HA C stated: Staying in break room or at the nurses station. Stays on phone in excess. Videotaping residents on cell phone. A note at the bottom of the sheet dated [DATE] and signed by the ADM stated: Was filmed by accident and video was destroyed. Review of the progressive discipline form dated [DATE] and signed by the DON regarding HA D stated: Sitting in the break room and staying on the phone in excess. Walking up and down the hallway with phone in hand. Review of the facility policy and Procedure on Abuse Prohibition and Prevention provided by the ADM on [DATE] and dated [DATE] stated: It is the policy of this facility that we will not tolerate any kind of abuse of residents. The facility ADM was notified on [DATE] at 1:15 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the ADM on [DATE] at 5:50 p.m. The Plan of Removal was accepted at 10:30 a.m. on [DATE]. The facility took the following actions to remove the IJ: Problem: Videotaping Residents #1 in a compromised situation. CNA F and HA D were taunting and laughing at Resident #1. The DON, ADON, LVN C, CNA F, HA C, HA D were aware and of this and did not report this to the ADM. HA C did the actual videotaping. The ADM upon learning of this videotaping of Resident #1 did not report this incident to the proper authorities, did not investigate the incident, and did not follow the facility's procedures on abuse and neglect. Interventions: The Administrator held an in-service for staff on recognizing and reporting abuse and neglect on [DATE]. Thirty five employees attended. The subjects that were covered were: A. What is abuse? B. What to do if you suspect abuse. C. Who can report suspected abuse? D. How and where do you report abuse? E. Residents rights involving being treated with courtesy, consideration, respect, and privacy. F. Policy regarding cell phone usage. Abuse and Resident Rights will be a continued In-Service at each monthly meeting. Abuse reporting and cell phone policy will be reviewed with each employee upon hire and 1 on 1 at each employee's annual review. Cell phone usage in patient care areas is prohibited. All cell phones are to be kept out of site while on the clock. Staff will check all cell phones into the charge nurse at the start of the shift. Phones will be placed in the medication room. Cell phones may be check out from the med room while employees are on break or at lunch. When the break or lunch is over the phone will be checked back to the charge nurse and placed in the med room. The charge nurse will do walking rounds through the shower area to ensure there are no phones being used in resident care areas. A sign in sheet has been created for Q 2 hour shower rounds; these are to be initialed by the staff conducting the rounds. Any employee found in a resident care area with a cell phone will be subject to disciplinary action up to and including termination. It is the responsibility of every employee to report suspected abuse. Reports are to be made to your supervisor, charge nurse, ADON, DON, or Abuse Coordinator/Administrator. Upon notification of suspected abuse, the supervisor, charge nurse, ADON, or DON will immediately notify the Abuse Coordinator/Administrator. If a front line staff member wishes to report an allegation of abuse directly, they may contact the Abuse Coordinator/Administrator at any time. The Abuse Coordinator will advise the staff of the appropriate action to take. If a staff member is involved in the allegation, they are to be suspended from work until the investigation is complete. After the abuse Coordinator has been notified of a suspected case, a call will be placed to the Provider Self reporting hotline to report the allegation. If the Abuse Coordinator is not available the DON will make this phone call. In the absence of the DON, the ADON will make this phone call. If the ADON is not available the charge nurse may call the hotline. The DADS form 3613-A is kept ub tge Abuse policy book at the nurse ' s station which is available at all times. The person alleging suspected abuse will make a statement with facts, times, dates, occurrences, and names of anyone involved. The 3619 will be faxed to DADS within 5 working days. If the internal investigation substantiates the allegation, appropriate disciplinary action up to termination will take place. As of Friday [DATE], the following staff has been suspended pending the investigation of abuse: DON, ADON, LVN C, CNA F, HA C, and HA D. Interviews with 10 different staff members on [DATE] from 11:40 a.m. to 1:50 p.m. revealed all had been in serviced on abuse and neglect. They all stated they would report any allegation of abuse to the ADM. They had been told that cell phones were no to be on their person and when checking with all above parties, no cell phones were present on staff. Observation of the medication room on [DATE] at 11:55 a.m. revealed a basket with cell phones on the counter. Observation of the shower sheets revealed that this was initiated on [DATE] starting at 3:00 p.m. and has been completed every two hours since that time. Interviews were conducted by the ADM on [DATE] with 7 residents in the facility asking if they had ever been abused or mistreated at the facility. Residents were also asked if they felt safe at the facility. Interviews were conducted with 21 staff members starting on [DATE] through [DATE]. In the interviews staff was asked if they had seen any abuse of residents in the facility and if they did who they would report it to. The Administrator was informed that the immediacy of the IJ was removed on [DATE] at 10:30 a.m., however the facility, remained out of compliance at a severity level of harm and a scope of a widespread, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The ADM provided census on [DATE] was 23.

Based on interview and record review the facility failed to ensure that all allegations involving mistreatment, neglect or abuse for 1 of 6 residents (Resident #1) are investigated thoroughly and reported immediately to protect residents from further abuse. The facility failed to immediately report to the State Agency an allegation of abuse and neglect involving Resident #1 and CNA A in the spring of 2013. CNA A continued to work at the facility until July of 2013, when CNA A was terminated. The facility failed to investigate an allegation of abuse and neglect by not reporting this to the administrator, interviewing residents, CNA ' s and all persons involved. This failure placed Resident #1 in fear for her safety, security and mental health from early spring until she again reported these same allegations to the DON in July of 2013. In addition, this failure could affect all 24 residents residing in the facility, placing them all at risk for abuse and neglect. Findings include: During an interview with Resident #1, on 8-30-13 at 10:35 a.m., it was revealed that in early spring of 2013 and again in July of 2013, Resident #1 had gone to the DON with a complaint of abuse: verbal, physical and mental from CNA A. Resident #1 stated that CNA A would handle Resident #1 very roughly, talk very loudly and be very rude. Resident #1 stated that when CNA A was performing peri-care, CNA A would roll Resident #1 roughly over on Resident #1 ' s side, pushing Resident #1 into the side rails on the bed. Resident #1 stated that when requesting to use the potty chair, CNA A would tell Resident #1 no, just pee on the pad in the bed. Resident #1 would again ask CNA A to use the potty chair and CNA A told Resident #1 to just pee in the bed and then CNA A would change the linens. Resident #1 stated this caused her great stress. Resident #1 would dread CNA A coming on shift and Resident #1 voiced this to Resident #2 on multiple occasions. Resident #1 and Resident #2 felt like something should have been done when this was first reported to the DON in the spring. During an interview with Resident #2 on 8-30-13 at 10:35 a.m., Resident #2 stated that CNA A felt untouchable, Resident #2 stated that Resident #1 would state " Oh no!, CNA A is going to be working for 12 hours, I don ' t know what I am going to do. " Resident #2 stated that they fired CNA A in July, but she took a position as a personal assistant to a resident at the facility. Resident #2 stated that CNA A would come in and out of the facility to pick up this resident. Resident #2 and Resident #1 stated that this caused Resident #1, mental anguish, and Resident #1 was worried that this CNA A was still coming into the facility. Resident #2 stated that Resident #1 is so much happier now that CNA A is not in the facility. Resident #2 stated it is a noticeable difference. During an interview with Resident #4, on 8-30-13 at 10:15 a.m., Resident #4 stated that she had a little trouble with CNA A, " she would holler, scream and she was rough. " Resident #4 stated: " CNA A has not been here recently. " During an interview with Resident # 6, on 8-30-13 at 11:00 a.m., Resident #6 stated: " I have had a problem with CNA A. " " CNA A was loud, boisterous, inattentive to resident ' s needs. " . Resident #6 stated " once residents were in bed, she would watch television and she would ignore resident ' s needs. " " She would act irritated if you asked her for help of any kind. " During an interview on 8-30-13 at 10:35 a.m. with Resident #1, Resident #1 stated she had complained to the DON about CNA A during the spring of 2013 for the same complaint that was reported by the facility in July. (Resident #1 could not remember what month this occurred, just knew it was in the spring). Resident #1 stated nothing was ever done in regard to that complaint. CNA A continued to work until second complaint was filed in July. During an interview with DON on 8-30-13 at 11:25 a.m., DON confirmed that Resident #1 had come to her in the spring of 2013 with the same allegation that was reported in July. When the DON was asked why it was not reported to the Administrator or to the State, The DON stated "I did not know it was abuse at that time." "I should have fired CNA A at that time." DON stated there was no reporting to the Administrator, State, or were there any interviews with residents at risk for abuse and neglect, or other CNA 's in the facility, or any person involved in the allegations. During an interview with the administrator on 8-30-13 at 1:15 p.m., the Administrator stated she was unaware that this complaint about CNA A was made in the spring of 2013. When asked what Administrator would expect in regards to reporting abuse and neglect, she stated she should have been notified by the DON, and we would need to notify the State. I would expect for us to follow our policy on abuse and neglect. Summary of relevant information from record reviews: Record review of the complaint/grievance log showed no complaints of abuse or neglect recorded for Resident #1 or any resident in the facility. The policy and procedure states: Upon receipt of a grievance or complaint report, the department head in charge of the area of concern will begin an investigation in the allegations. The investigation report will include, as each may apply: A. The date and time of the alleged incident. B. The circumstances surrounding the alleged incident. C. The location of the alleged incident. D. The names of any witnesses and their account of the alleged incident. E. The resident ' s account of the alleged incident. F. The employee ' s account of the alleged incident. G. Accounts of any other individuals involved (i.e., employee ' s supervisor, etc.): and H. Recommendations for corrective action. The Resident Grievance/Complaint Investigation Report Form must be filed with the administrator with three working days of the receipt of the grievance or complaint form. Record Review of the facilities policies and procedures for abuse and neglect state that they are to secure the safety of the resident, Call into State, Investigate and Fax or Mail within 5 working days of the oral report. There is no record of any grievance filed in the spring against CNA A by Resident #1. DON has admitted that Resident #1 did come to DON with a complaint of abuse and neglect in the spring. The Administrator was not notified. There was no report filed. No call to State Agency and no investigation done. Review of the Facility Roster, received from the facility on 8-30-13, documented 24 residents.

Based on interview and record review the facility failed to follow their written policy and procedure for abuse and neglect, when an allegation involving mistreatment, neglect or abuse was not investigated thoroughly and reported immediately to protect 1 of 6 sampled residents (Resident #1) from further abuse. The facility failed to immediately report to the State Agency an allegation of abuse and neglect involving Resident #1 and CNA A in the spring of 2013. CNA A continued to work at the facility until July of 2013 , when CNA A was terminated. THe facility failed to investigate an allegation of abuse and neglect by not reporting this to the administrator, interviewing residents, CNA's and all persons involved. This failure placed Resident #1 in fear for her safety, security and mental health from early spring until she again reported these same allegations to the DON in July of 2013. In addition, this failure could affect all 24 residents residing in the facility, placing them all at risk for abuse and neglect. Findings include: Record Review of the Grievance and Complaint Log shows no notation of Allegation of abuse or neglect for Resident #1 or any resident. Policy and Procedure for the Grievance and Complaint Procedure is as follows: Upon receipt of a grievance or complaint report, the department head in charge of the area of concern will begin an investigation in the allegations. The investigation report will include, as each may apply: A. The date and time of the alleged incident. B. The circumstances surrounding the alleged incident. C. The location of the alleged incident. D. The names of any witnesses and their account of the alleged incident. E. The resident ' s account of the alleged incident. F. The employee ' s account of the alleged incident. G. Accounts of any other individuals involved (i.e., employee ' s supervisor, etc.): and H. Recommendations for corrective action. The Resident Grievance/Complaint Investigation Report Form must be filed with the administrator with three working days of the receipt of the grievance or complaint form. Record Review of the facilities policies and procedures for abuse and neglect documented they are to secure the safety of the resident, Call into State, Investigate and Fax or Mail within 5 working days of the oral report. There is no record of any grievance filed in the spring against CNA A by Resident #1. DON has admitted that Resident #1 did come to DON with a complaint of abuse and neglect in the spring. The Administrator was not notified. There was no report filed. There was no documentation of a call to State Agency or an investigation. During an interview with Resident #1, on 8-30-13 at 10:35 a.m., it was revealed that in early spring of 2013 and again in July of 2013, Resident #1 had gone to the DON with a complaint of abuse: verbal, physical and mental from CNA A. Resident #1 stated that CNA A would handle Resident #1 very roughly, talk very loudly and be very rude. Resident #1 stated that when CNA A was performing peri-care, CNA A would roll Resident #1 roughly over on Resident #1 ' s side, pushing Resident #1 into the side rails on the bed. Resident #1 stated that when requesting to use the potty chair, CNA A would tell Resident #1 no, just pee on the pad in the bed. Resident #1 would again ask CNA A to use the potty chair and CNA A told Resident #1 to just pee in the bed and then CNA A would change the linens. Resident #1 stated this caused her great stress. Resident #1 would dread CNA A coming on shift and Resident #1 voiced this to Resident #2 on multiple occasions. Resident #1 and Resident #2 felt like something should have been done when this was first reported to the DON in the spring. During an interview with Resident #2 on 8-30-13 at 10:35 a.m., Resident #2 stated that CNA A felt untouchable. Resident #2 stated that Resident #1 would state, #2, "Oh no, CNA A is going to be working for 12 hours, I don't know what I am going to do." Resident #2 stated that they fired CNA A in July, but she took a position as a private assistant to a resident at the facility. Resident #2 stated that CNA A would come in and out of the facility to pick up this resident. Resident #2 and Resident #1 stated that this caused Resident #1 mental anguish, and Resident #1 was worried that CNA A was still coming into the facility. Resident #2 stated that Resident #1 is so much happier now that CNA A is not in the facility. Resident #2 stated it is a noticeable difference. During an interview with Resident #4, on 8-30-13 at 10:15 a.m., Resident #4 stated that she had a little trouble with CNA A, " she would holler, scream and she was rough. " Resident #4 stated: " CNA A has not been here recently. " During an interview with Resident #6, on 8-30-13 at 11:00 a.m., Resident #6 stated that "CNA A was boisterous, loud and inattentive to resident's needs." Resident #6 stated that "once residents were in bed, she would watch television and she would ignore resident's needs and would act irritated if you asked her for help of any kind." During an interview with the DON on 8-30-13 at 11:25 a.m., the DON was told that Resident #1 stated she had come to the DON in the spring of 2013 with the same complaint about CNA A as the July complaint. When the DON was asked why this was not reported in the spring, DON stated " I should have fired CNA A then. " DON stated there is no written documentation of grievance/complaint, interviews or anything pertaining to the complaint in the spring of 2013, regarding Resident #1, CNA A or other residents at the facility. DON stated, " I did not write that down. " During an interview with the DON on 8-30-13 at 1:05 p.m., The DON thought it was a problem with CNA A performing incontinent care by herself. DON stated that she told CNA A to not make Resident #1 uncomfortable and be gentle with her. The DON also stated she didn't have interview notes with Resident #1, or any interview of residents in the facility or staff in the facility. During an interview of the Administrator on 8-30-13 at 1:15 p.m., the Administrator stated she would expect to be told if there were any allegations of abuse and neglect. It should have then been reported to the State and they should have followed their abuse and neglect policy. Record Review of Termination Notice for CNA A stated CNA A was terminated for being loud, generally rude, and abusing residents by refusing to take them to the bathroom. Review of the Facility Roster, received from the facility on 8-30-13, documented 24 residents.

Based on interview, and record review, the facility failed to ensure goods and services necessary to avoid physical harm and mental anguish, for 1 of 6 residents (Resident #1) reviewed for physical, mental and verbal abuse. Resident #1 went to the DON in early spring of 2013 with the allegation of physical, mental and verbal abuse form CNA A. This allegation in the spring was not reported to the administrator of the facility, was not reported to the State Agency, was not investigated, or followed up on by the DON of the facility. This failure placed Resident #1 in fear for her safety, security and mental health from early spring until she again reported these same allegations to the DON in July of 2013. In addition, this failure could affect all 24 residents residing in the facility, placing them all at risk for abuse and neglect. Findings include: During an interview with Resident #1, on 8-30-13 at 10:35 a.m., it was revealed that in early spring of 2013 and again in July of 2013, Resident #1 had gone to the DON with a complaint of abuse: verbal, physical and mental from CNA A. Resident #1 stated that CNA A would handle Resident #1 very roughly, talk very loudly and be very rude. Resident #1 stated that when CNA A was performing peri-care, CNA A would roll Resident #1 roughly over on Resident #1's side, pushing Resident #1 into the side rails on the bed. Resident #1 stated when requesting to use the potty chair, CNA A would tell Resident #1 no, just pee on the pad in the bed. Resident #1 would again ask CNA A to use the potty chair and CNA A told Resident #1 to just pee in the bed and then CNA A stated she would change the linens. Resident #1 stated this caused her great stress. Resident #1 would dread CNA A coming on shift and Resident #1 voiced this to Resident #2 on multiple occasions. Resident #1 and Resident #2 felt like something should have been done when this was first reported to the DON in the spring. During an interview with Resident #2 on 8-30-13 at 10:35 a.m., Resident #2 stated that CNA A felt untouchable, Resident #2 stated that Resident #1 would state, " Oh no!, CNA A is going to be working for 12 hours, I don't know what I am going to do". " Resident #2 stated that they fired CNA A in July, but she took a position as a personal assistant to a resident at the facility. Resident #2 stated that CNA A would come in and out of the facility to pick up this resident. Resident #2 and Resident #1 stated that this caused Resident #1, mental anguish, and Resident #1 was worried that this CNA A was still coming into the facility. Resident #2 stated that Resident #1 is so much happier now that CNA A is not in the facility. Resident #2 stated it is a noticeable difference. During an interview with Resident #4, on 8-30-13 at 10:15 a.m., Resident #4 stated that she had a little trouble with CNA A, " she would holler, scream and she was rough." Resident #4 stated: " CNA A has not been here recently. " During an interview with Resident # 6, on 8-30-13 at 11:00 a.m., Resident #6 stated: " I have had a problem with CNA A, she was loud, boisterous, inattentive to resident's needs." Resident #6 stated "once residents were in bed, she would watch television and would ignore resident's needs, she would act irritated if you asked her for help of any kind." During an interview with the DON on 8-30-13 at 10:30 a.m., the DON stated there had been complaints of CNA A being loud, turning on lights at 5:00 a.m., before residents wanted to get up. DON states that another CNA came into her office and stated she would not work with CNA A. The DON stated residents that were harder to take care of CNA A would lose patience with them. During an interview with the DON on 8-30-13 at 11:25 a.m., the DON was told that Resident #1 stated she had come to the DON in the spring of 2013 with the same complaint about CNA A as the July complaint. When the DON was asked why this was not reported in the spring, DON stated " I should have fired CNA A then." DON stated there is no written documentation of grievance/complaint, interviews or anything pertaining to the complaint in the spring of 2013, regarding Resident #1, CNA A or other residents at the facility. DON stated, "I did not write that down." During an interview with the DON on 8-30-13 at 1:05 p.m., The DON thought it was a problem with CNA A performing incontinent care by herself. DON stated that she told CNA A to not make Resident #1 uncomfortable and be gentle with her. The DON also stated she didn't have interview notes with Resident #1, or any interview of residents in the facility or staff in the facility. During an interview with the Administrator on 8-30-13 at 1:15 p.m., The Administrator stated Administrator knew nothing about Resident #1 making the first complaint against CNA A in the spring. Administrator stated she would expect the DON to report this to her and they would need to notify the State. Administrator stated she would expect them to follow the abuse and neglect policy and procedure. During a telephone interview with CNA A on 8-30-13 at 2:00 p.m. CNA A states " I have never handled a resident roughly." " I work nights and I always find something to keep myself busy." I clean wheel chairs, and answer call lights." "I always take residents to the restroom if they ask." Summary of relevant information from record reviews: Record Review of Resident #1's clinical record documented an admitted [DATE]. Resident #1's date of birth is 8-21-45, with the following Diagnosis: [REDACTED]. The quarterly MDS dated [DATE] for Resident #1, states that Resident #1 is totally dependent on staff for transfers, dressing and hygiene. The quarterly MDS dated [DATE] states Resident#1 is occasionally incontinent of bladder and always continent of bowel. Record review of termination notification for CNA A is dated 7-14-13. It states that CNA A was terminated for being loud, generally rude and abusing residents by refusing to take them to the bathroom. Record review of the complaint/grievance log showed no complaints of abuse or neglect recorded. There is no record of the grievance by Resident #1 in the spring against CNA A. Review of the Facility Roster received from the facility on 8-30-13, documented 24 residents.