Every finding on record at Monticello Healthcare

Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value related to not following instructions for puree food preparation. This had the potential to affect 5 residents who received a pureed diet from the kitchen. Finding includes: On 5/14/25 at 10:50 a.m., [NAME] 1 was observed preparing pureed food. She indicated she was going to puree chicken patties. She washed her hands and removed a pan of chicken patties from the oven. She placed 6 chicken patties in the blender and blended them. She stopped the blender, added two cups of water from the faucet, and blended again. She stopped the blender, stirred the contents with a spatula, added another cup of water, and blended longer. She stopped the blender, stirred the contents, added one scoop of thickener, and blended again. She stopped the blender, stirred the contents, checked the consistency using spoon tilt test (a test used to determine correct puree consistency), and resumed blending. She stopped the blender, stirred the contents, checked the consistency again, added one more scoop of thickener, and blended. She stopped the blender, stirred the contents, checked the consistency a final time, indicated she was done making the puree, and put the contents of the blender into a pan to be served. During an interview on 5/14/25 at 11:03 a.m., [NAME] 1 indicated the kitchen staff used to have a book of pureed recipes, but they no longer had it. During an interview on 5/14/25 at 11:04 a.m., the Dietary Manager indicated they no longer used pureed recipes. The corporation had gotten rid of the recipes, and they were now to follow the IDDSI (International Dysphagia Diet Standardization Initiative) guidelines. The pureed food just had to pass either the spoon tilt test or the fork drip test to be the correct consistency. There were no guidelines on how much liquid, what type of liquid, or how much thickener to add to a pureed food when preparing it. They started out by blending whatever food they were making and went from there to determine if they should add some liquid or thickener. They typically would not use water as the liquid but instead would use the broth of whatever item they were preparing, for example when preparing a chicken item they would use chicken broth. During an interview on 5/14/25 at 3:40 p.m., the Administrator was made aware of the concern with the pureed preparation and had no further information to provide. An IDDSI Notes document, undated and provided as current by the Administrator, indicated, .For pureed: Measure desired number of servings into food processor. Blend until smooth. Add broth or gravy with meats, and milk or water for other foods if product does not meet proper consistency per IDDSI guidelines. Commercial thickener should be added as necessary to achieve proper consistency . 3.1-21(a)(1)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to insulin use for 1 of 18 MDS assessments reviewed. (Resident 52). Finding includes: The record for Resident 52 was reviewed on 5/15/25 at 9:38 a.m. Diagnoses included, but were not limited to, Parkinson's disease, diabetes, and schizophrenia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/14/25, indicated the resident received insulin. The Medication Administration Record (MAR) for March 2025 indicated the resident received Ozempic (semaglutide) (a medication for diabetes and weight loss) once a week. The record lacked documentation the resident received insulin during the MDS assessment period. During an interview on 5/15/25 at 11:30 a.m., the MDS Coordinator indicated she thought she should code that the resident received insulin because Ozempic lowers blood sugar. She indicated she would reach out to her consultant for supporting documentation/guidance. No further information was received. During an interview on 5/16/25 at 2:27 p.m., the Director of Nursing (DON) indicated Ozempic should be coded as an injected medication, but not as insulin. A policy titled, 5 Supportive Documentation Requirements Table, received as current on 5/16/25 at 3:31 p.m. from the Administrator, indicated, .Documentation must be consistent with physician orders and insulin administration records . 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 1 of 7 residents reviewed for non-pressure related skin conditions. (Resident B) Finding includes: On 5/13/25 at 11:12 a.m., Resident B was observed sitting in a wheelchair in the dining area. The wheelchair had padding on the arms. A large dark purple discoloration was observed to the resident's left elbow. On 5/14/25 at 10:26 a.m., Resident B was observed being wheeled out of her room in her wheelchair by her son. The dark purple discoloration was still observed to her left elbow. Record review for Resident B was completed on 5/14/25 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance for bathing, dressing, and transfers. The resident had a life expectancy of less than 6 months and was on hospice services. A Care Plan, dated 9/3/24 and revised 3/11/25, indicated the resident was at risk for skin breakdown or further skin breakdown due to impaired mobility with increased weakness. An intervention included to assess and document skin condition weekly and as needed and to notify the physician of abnormal findings. Another intervention included to have padded arm rests to the wheelchair. A Weekly Skin Assessment, dated 5/13/25, indicated the resident had no skin integrity alterations and bruising was not indicated. The record lacked any documentation to indicate the resident's discoloration had been assessed or was being monitored. During an interview on 5/14/25 at 10:50 a.m., LPN 1 indicated she was unaware of the resident's discoloration to her left elbow. During an interview on 5/16/25 at 3:00 p.m., the Director of Nursing (DON) indicated there was no prior documentation the resident's discoloration had been assessed or was being monitored. A facility policy, titled Skin Management Program, received as current, indicated .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported . This citation relates to Complaint IN00459697. 3.1-37(a)

Based on record review and interview, the facility failed to fully implement care-planned dietary interventions for a resident at risk for weight loss related to incomplete meal consumption logs and a lack of supplement/substitute documentation for 1 of 18 records reviewed. (Resident C) Finding includes: Resident C's record was reviewed on 5/15/25 at 12:52 p.m. Diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 4/15/25, indicated the resident was severely cognitively impaired. The resident required setup help for eating. A Care Plan, dated 11/29/24, indicated the resident required assistance and/or monitoring for AM/PM care, nutrition, hydration, and elimination. Interventions included, but were not limited to, record breakfast, lunch, dinner, and fluid intake percentage. A Care Plan, dated 12/3/24, indicated the resident was at nutritional risk related to COPD, diabetes mellitus, dementia, and chronic kidney disease. Interventions included, but were not limited to, honor preferences, monitor weight, offer substitution if resident consumes less than 50% of a meal, and provide diet as ordered. A Registered Dietician Nutritional Review, dated 4/22/25 at 4:02 p.m., indicated the resident had an average meal consumption of 55% for three meals a day. The resident was able to communicate meal choices and feed himself. The resident weighed 145 pounds (lbs) on 4/22/25, 146 lbs on 4/14/25, and 148 lbs on 4/8/25. The resident's usual/desirable body weight range was 150-155 lbs. The Plan of Care/Interventions indicated the resident's weight had increased and he preferred to eat in his room but was encouraged to attend meals in the dining room. The Plan of Care was to be continued and to honor the resident's preferences. The Intake: Breakfast, Lunch, Dinner, and Supplements Point of Care from 4/19/25 to 5/19/25 indicated the resident consumed between 1-50% of the following meals: - breakfast: 4/19, 4/23, 4/24, 4/25, 4/29, 4/30, 5/9, 5/11, and 5/12/25 - lunch: 4/19, 4/20, 4/23, 4/24, 4/25, 4/26, 4/28, 4/29, 4/30, 5/2, 5/9, and 5/14/25 - dinner: 4/19, 4/22, 4/23, 4/24, 4/26, 4/27, 4/29, 4/30, 5/1, 5/2, 5/4, 5/5, 5/7, 5/9, and 5/14/25 There was no documentation of a supplement or substitute offered on the above dates. There was no documentation of any intake for dinner on 4/25/25, breakfast on 4/28/25, dinner on 5/6/25, and lunch on 5/10/25. During an interview on 5/19/25 at 3:30 p.m., the Director of Nursing (DON) indicated the staff were to document substitutes given with the Supplement Point of Care documentation under the Intake section. Substitutes were always available and offered, however it was not documented. The resident had been gaining weight. A policy titled, Delivery and Documentation of Meal Service and Between Meal Nourishments, indicated .Documentation The nursing Department will document foods/fluids consumed at each meal using percentage eaten and fluids consumed in ml's. The dining room assistant or licensed nurse offers a substitute in the event the resident's nutritional intake is 50% or less at any meal and document acceptance or refusal . This citation relates to Complaint IN00459697. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident who required respiratory care received oxygen as ordered by the physician for 1 of 2 residents reviewed for respiratory care. (Resident B) Finding includes: On 5/13/25 at 10:58 a.m., Resident B was observed sitting in a wheelchair in the dining area. The resident was watching television with other residents. The resident had a portable oxygen attached to the back of her wheelchair. The oxygen was on the resident via a nasal cannula and set at 3 liters. On 5/14/25 at 10:26 a.m., Resident B was observed being wheeled out of her room in her wheelchair by her son. The resident was awake and had oxygen on via a nasal cannula and set at 3 liters. Record review for Resident B was completed on 5/14/25 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance for bathing, dressing, and transfers. The resident had a life expectancy of less than 6 months and was on hospice services. The resident received oxygen therapy. A Care Plan, dated 9/3/24 and revised 2/21/25, indicated the resident had potential for impaired gas exchange related to respiratory failure. The resident wore oxygen. An intervention included to administer oxygen as ordered by the physician. The May 2025 Physician's Order Summary (POS) indicated an order for oxygen at 3 liters per nasal cannula while sleeping or napping, every shift. During an interview on 5/14/25 at 10:50 a.m., LPN 1 indicated the resident needed to wear her oxygen at all times. She would have to clarify the order to only wear it while sleeping or napping with the physician. During an interview on 5/16/25 at 3:00 p.m., the Director of Nursing (DON) indicated the order for the oxygen had been changed to continuously at 3 liters. A facility policy, titled Oxygen-Liquid, received as current, indicated .Procedure 1. Verify physician orders. Know the flow rate and duration of use . 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure there was adequate monitoring of vital signs per the physician's orders prior to the administration of a medication that alters the rate/rhythm of the heart for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: Resident 22's record was reviewed on 5/14/25 at 2:09 p.m. Diagnoses included, but were not limited to, dementia, Parkinson's disease, and atrial fibrillation (irregular heart beat). The Significant Change in Status Minimum Data Set (MDS) assessment, dated 4/20/25, indicated the resident was moderately cognitively impaired. A Care Plan, dated 9/20/22, indicated the resident received digoxin (medication that alters the rate and rhythm of the heart). Interventions included, but were not limited to, administer medications as ordered, check pulse prior to administering medications, and observe for symptoms of toxicity. A Physician's Order, dated 4/15/25, indicated digoxin 62.5 micrograms (mcg) one tablet at 6:00 a.m. daily. Hold the medication for pulse less than 60 beats per minute. The April and May 2025 Medication Administration Record lacked any documentation of the resident's heart rate being monitored at the time of digoxin administration. The medication was marked as administered daily. During an interview on 5/16/25 at 10:10 a.m., the Director of Nursing indicated the resident had been in the hospital and when she had readmitted on [DATE], the order was implemented, however it was not marked for the nursing staff to document the heart rate with each administration of the medication. 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with professional standards related to medications for multiple residents stored in the cabinet without the resident's name, medication name, prescribed dose, strength, and expiration date for 1 of 2 medication rooms observed. (Residents D, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, and Z) Finding includes: During an observation of the BCD Unit Medication room on 10/15/24 at 4:35 p.m., there were multiple paper medication cups stored with medication in the cups. The medication cups had another paper medication cup covering the medications. The medication cups used to cover the medications had initials and a 5, 6, or 7 written on them. During an interview at the time of the observation, LPN 1 indicated the medications in the medication cups were for the 5 p.m., 6 p.m., and 7 p.m. medication passes for Residents D, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, and Z. The medications should not have been set up and stored prior to the medication administration. During an interview on 10/15/24 at 4:40 p.m., the Director of Nursing indicated the medications were not to be set up and stored in the medication room prior to the medication administration times. A facility procedure for medication administration, dated 7/2023 and received as current from the Administrator, indicated medications were to be prepared for one resident at a time. A facility policy for storage of medications, dated 8/2024 and received from the Administrator as current, indicated the facility was to ensure the medications for each resident were stored in containers they were originally received in. This citation relates to Complaints IN00443901 and IN00444365. 3.1-25(j)

Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to broken and missing blind slats, chipped paint, marred walls, and loose stripping for 3 of 4 units observed. (Cottage, BCD, and [NAME] Units) Findings include: During the Environmental Tour, on 3/7/24 at 10:40 a.m., the following was observed: 1. Cottage room [ROOM NUMBER]- Stripping surrounding the air conditioner was loose and hanging. Two residents resided in the room. room [ROOM NUMBER]- Slats missing from window blind, peeling paint and caulk above the window and marred walls in the bathroom. Two residents resided in the room. 2. BCD room [ROOM NUMBER]- Slats were broken off the window blinds. One resident resided in the room. room [ROOM NUMBER]- Marred walls with chipped paint next to bed by the door. Two residents resided in the room. room [ROOM NUMBER]- Slats missing from window blind and chipped paint on the window trim. Two residents resided in the room. room [ROOM NUMBER]- Slats broken on window blinds and marred door frame to the bathroom. Two residents resided in the room. 3. West room [ROOM NUMBER]- Slats missing from the bathroom window blind. One resident resided in the room. During an interview with the Maintenance Director at that time, he indicated the items were in need of repair and he would fix them. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure assessment and monitoring of skin discolorations, for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 50) Finding includes: On 3/3/24 at 3:25 p.m. Resident 50 was observed lying in bed. There were multiple dark purple discolorations to his right arm and a white bandage in place to his right elbow. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. On 3/5/24 at 10:21 a.m., Resident 50 was observed lying in bed. There were multiple dark purple discolorations to his right arm. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. On 3/6/24 at 12:31 p.m., Resident 50 was observed sitting up in bed eating lunch. There were multiple dark purple discolorations to his right arm. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. Record review for Resident 50 was completed on 3/4/24 at 12:57 p.m. Diagnoses included, but were not limited to, hypertension, vascular dementia, and cardiomyopathy. The Quarterly Minimum Data Set (MDS) assessment, dated 12/15/23, indicated the resident was moderately cognitively impaired, received antiplatelet medication, and required assistance from staff with ADLs (activities of daily living). A Care Plan, updated 1/2/24, indicated the resident was at risk for bleeding and bruising due to taking an antiplatelet medication. Interventions included to observe for increased bleeding or bruising. The Weekly Skin and Vital Sign Assessments, dated 2/20/24, 2/27/24, and 3/5/24, lacked any documentation of the discolored areas to the resident's right arm. The Physician's Order Summary, dated 3/2024, indicated the resident was to wear geri sleeves (protective sleeves) or long sleeves and to monitor the skin to the upper extremities every shift. There were also orders for aspirin 81 mg (milligrams) daily and clopidogrel (Plavix, an antiplatelet medication) 75 mg daily. The Medication Administration Record (MAR), dated 3/2024, indicated the resident received the aspirin and clopidogrel medications daily as ordered. The geri sleeves and skin monitoring were signed off every shift. There were no documented refusals or issues noted with the skin. During an interview with the Assistant Director of Nursing (ADON) on 3/6/24 at 2:53 p.m., she indicated she would complete a skin assessment for the resident and document any discolorations. A facility policy, titled Skin Management Program, received as current, indicated .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported .Procedure for alterations in skin integrity .4. All newly identified areas after admission will be documented on the New Skin Event. 5. The wound nurse/designee will be notified of alterations in skin integrity .b) .ii) Wound management entries will be completed for non-ulcers (bruises, skin tear, abrasion, rashes). If no signs of complications or worsening in condition of skin alteration and doesn't meet the guideline for IDT weekly wound review the wound management entry can be closed after 72 hours . 3.1-37(a)

Based on observation and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food. This had the potential to affect 13 residents who received a pureed diet. (Main Kitchen, Cook 1) Findings include: On 5/3/23 at 11:00 a.m., Cook 1 was observed preparing pureed taco salad with chili. A recipe was used and the measured ingredients were prepared in advance. Two cycles were pureed through the blender to complete the taco salad puree portion of the recipe. The cook poured the pureed taco salad in to 13 bowls. The blender was washed and another cycle was performed to puree the chili. The chili was completed and the cook garnished the top of each 13 taco salad bowls with the chili. At 11:30 a.m., Cook 1 indicated that she was finished making the puree foods. The recipe was completed, besides adding sour cream, and the taco salad was ready to be served. At that time, the pureed food was observed to be watery and runny. At 11:32 a.m., interview with the Culinary Manager (CM) indicated there was too much water in the pureed taco salad and that they would not be serving them. The CM confirmed that the cook should have recognized the pureed salad was not the appropriate thickness and restarted the recipe sooner. The CM also indicated the cook would modify the recipe to add thickness and remake the 13 pureed taco salad dishes. 3.1-21 )(a)(3)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to gouged walls, holes in bathroom walls, a cracked toilet riser, and chipped paint on 3 of 4 units. (BCD Unit, West Wing, and Cottage). Findings include: During the Environmental tour with the Directors of Maintenance and Housekeeping and the Administrator on 5/9/23 at 2:40 p.m., the following was observed: 1. BCD Unit a. In room [ROOM NUMBER], the window had chipped paint and the wall in the bathroom had holes underneath the soap dispenser. Two residents resided in the room. Four residents shared the bathroom. b. In room [ROOM NUMBER], the toilet riser handles were cracked, the bathroom sink was slow to drain, there was a film buildup in the sink, and the wall had holes underneath the soap dispenser. Four residents shared the bathroom. c. In room [ROOM NUMBER], the window had chipped paint, the bottom corner of the wall by the closet was gouged, and the wall in the bathroom had holes underneath the soap dispenser. Two residents resided in the room. Four residents shared the bathroom. d. In room [ROOM NUMBER], the wall had gouges by the bed closest to the door. Two residents resided in the room. 2. West Wing a. In room [ROOM NUMBER], the walls were marred next to the bed by the door. Two residents resided in the room. b. In room [ROOM NUMBER], the toilet booster seat was uncovered and sitting on the floor of the bathroom. One resident used the bathroom. 3. Cottage a. In room [ROOM NUMBER], the walls by the bathroom door were gouged. Two residents resided in the room. b. In room [ROOM NUMBER], the walls behind bed 2 were gouged. Two residents resided in the room. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure a palm protector was in place for 1 of 1 residents reviewed for limited range of motion. The facility also failed to ensure an area of skin discoloration was assessed and monitored for 1 of 3 residents reviewed for skin conditions non pressure related, and leg wraps were in place for 1 of 2 residents reviewed for edema. (Residents 2, 36 and 66) Findings include: 1. On 5/3/23 at 2:01 p.m. and 5/4/23 at 1:49 p.m., Resident 2 was observed in bed. There was no palm protector (a splinting device used to prevent contractures) in place on his right hand. On 5/4/23 at 10:30 a.m., 5/5/23 at 10:39 a.m., and 5/5/23 at 12:46 p.m., the resident was observed seated in his reclining wheel chair and there was no palm protector in place on his right hand. The resident's record was reviewed on 5/5/23 at 10:41 a.m. Diagnoses included, but were not limited to, Cerebral Palsy and unspecified dementia. The Quarterly Minimum Data Set assessment, dated 3/16/23, indicated the resident had severe cognitive impairment and was dependent on staff assistance for transfers, eating and toileting. A Physician's Order, dated 3/23/23, indicated the resident was to have a palm protector in his right hand applied in the morning and removed at bedtime. The May 2023 Medication Administration Record indicated the palm protector was applied and removed every day. Interview with LPN 1 and QMA 1 on 5/5/23 at 12:50 p.m. in the resident's room, indicated the palm protector may have come off and was possibly in his clothing. They checked his blanket and clothing. The palm protector was located on the floor on the far side of his night table. 32664 2. On 5/3/23 at 11:23 a.m., Resident 36 was observed sitting in a recliner in her room. There were dark purple discolorations observed to the tops of both forearms, hands, and the top of the 3rd and 4th finger of her right hand. The resident indicated she bumped her arms and hands often on the wall and bed rail when she turned over in bed. On 5/5/23 at 2:17 p.m., Resident 36 was observed sitting in a recliner in her room. The same discolorations were still observed. Record review for Resident 36 was completed on 5/4/23 at 3:25 p.m. Diagnoses included, but were not limited to, heart failure, anemia, diabetes mellitus, and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment, dated 4/3/23, indicated the resident was cognitively intact. The resident required an extensive 2+ person assistance for bed mobility, transfers, and toilet use. A Care Plan, dated 8/1/22 and revised 4/7/23, indicated the resident was at risk for bleeding/bruising related to the use of antiplatelet medication. An intervention included to observe for increased bruising. A Skin Assessment, dated 5/2/23, indicated the resident had no areas of bruising. The record lacked any documentation to indicate the resident's discolorations had been assessed or were being monitored. Interview with the BCD Unit Manager on 5/5/23 at 2:22 p.m., indicated the discolorations on her forearms and the top of her left hand looked like her normal discolorations. The discolorations to the top of the right hand and fingers looked like bruising and the aides should have observed them with daily care and notified the nurse. 32788 3. On 5/4/23 at 10:59 a.m., Resident 66 was observed seated in her wheelchair in the dining room. Her bilateral lower extremities were swollen and the ace wraps to her legs were loose and sliding down. On 5/4/23 at 11:56 a.m., the resident was observed seated in her wheelchair in the dining room. Her bilateral lower extremities were swollen. There was no ace wrap in place to her right leg. The ace wrap to her left leg had fallen down around her ankle. Record review for Resident 66 was completed on 5/8/23 at 11:02 a.m. Diagnoses included, but were not limited to, lymphedema, hypertension, and fluid overload. A current care plan indicated the resident was at risk for skin breakdown due to increased edema to her bilateral lower extremities. She was also at risk for weight fluctuations related to lymphedema and a history of fluid overload. The Weekly Skin and Vital Sign Assessment, dated 5/2/23, indicated the resident had edema to the bilateral lower extremities. A Physician's Order, dated 4/18/23, indicated four-layer compression wraps to bilateral lower legs for lymphedema. Change every other day and as needed for dislodgement or soilage. The Medication and Treatment Administration Records, dated 5/2023, indicated the leg wraps had been changed on 5/4/23 and 5/6/23. They were due to be changed on 5/8/23 at 8 p.m. Interview with the DON on 5/8/23 at 3:32 p.m., indicated the wraps should have been in place as ordered. No further information was provided. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a nutritional supplement was given as ordered for 1 of 4 residents reviewed for nutrition. (Resident 66) Finding includes: On 5/8/23 at 12:15 p.m., the resident was observed seated in her wheelchair in the dining room. The lunch trays were delivered to the unit and the staff started passing out the trays. At 12:20 p.m., the resident received her lunch and began eating. She received a fish sandwich, french fries, cantaloupe, and coleslaw. She had coffee and chocolate milk to drink. She had not received any fortified pudding. Record review for Resident 66 was completed on 5/8/23 at 11:02 a.m. Diagnoses included, but were not limited to, lymphedema, hypertension, and fluid overload. The Admission Minimum Data Set (MDS) assessment, dated 3/8/23, indicated the resident was cognitively impaired and required extensive assistance of one with eating. A current Care Plan indicated the resident was at risk for weight fluctuations related to lymphedema and a history of fluid overload. The resident weighed 209 pounds on 4/3/23 and 199 pounds on 5/3/23. A Registered Dietician Note, dated 4/4/23, indicated the resident was not currently meeting her estimated nutrition needs with her oral intakes. The resident had a preference for pudding and fortified pudding at lunch was recommended. A Physician's Order, dated 4/5/23, indicated regular diet with fortified pudding at lunch. Interview with the DON on 5/8/23 at 3:32 p.m., indicated she was not sure why the resident hadn't received the fortified pudding. No further information was provided. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident's pain medication was administered as ordered for 1 of 1 residents reviewed for pain. (Resident B) Finding includes: Interview with Resident B on 5/3/23 at 10:49 a.m., indicated her pain was controlled with the pain medications she received regularly. Resident B's record was reviewed on 5/5/23 at 10:25 a.m. Diagnoses included, but were not limited to, fibromyalgia, osteoarthritis, and Parkinson's Disease. The Quarterly Minimum Data Set assessment, dated 4/1/23, indicated the resident was cognitively intact, and received scheduled and as needed pain medications. The Physician's Order Summary, dated 5/2023, indicated the following pain medication orders: - Tylenol (acetaminophen) chewable 650 mg (milligrams) twice a day. Not to exceed 3 g (grams - 3000 mg) of acetaminophen from all sources in 24 hours. - Tylenol 650 mg every 6 hours PRN (as needed). Not to exceed 3 g of acetaminophen from all sources in 24 hours. - Hydrocodone-acetaminophen 5-325 mg four times a day. Not to exceed 3 g of acetaminophen from all sources in 24 hours. - Hydrocodone-acetaminophen 5-325 mg every four hours PRN. Not to exceed 3 g of acetaminophen from all sources in 24 hours. The Medication Administration Record, dated 5/2023, indicated the resident received the scheduled pain medications as well as the 650 mg PRN dose of acetaminophen on 5/2/23. The total dose of acetaminophen the resident received on 5/2/23 was 3250 mg, which was greater than 3 grams/ 3000 mg. The Medication Administration Record, dated 4/2023, indicated the resident received her scheduled pain medications as well as the 650 mg PRN dose of acetaminophen on 4/3/23, 4/5/23, 4/12/23, 4/15/23, 4/26/23 and 4/30/23. The total dose of acetaminophen the resident received on those dates was 3250 mg, which was greater than 3 grams/ 3000 mg. Interview with the DON on 5/8/23 at 3:32 p.m., indicated she would review the pain medication orders. No further information was provided. This Federal tag relates to Complaint IN00407457. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident received routine and/ or emergency dental services related to lack of an oral assessment for a resident complaining of mouth pain and swollen gums for 1 of 2 residents reviewed for dental services. (Resident 23) Finding includes: On 5/3/23 at 11:48 a.m., Resident 23 was observed in her room and her top dentures were removed. The upper gums were red and swollen and the resident indicated they were painful. She indicted this had been going on for 6 months. On 5/4/23 3:35 p.m., the resident was observed in her bed. She indicated she was unable to eat her lunch due to her mouth sensitivity and she was also unable to sleep due to the pain. The resident's record was reviewed on 5/4/23 2:19 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anxiety, depression, and myalgia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/21/23, indicated the resident was cognitively intact and had no dental issues. A Dental Care Plan, revised 4/4/23, indicated the resident had no natural teeth. Approaches were to observe and document for red/bleeding gums, lesions, symptoms of pain, to notify the physician, and obtain dental consult as needed. A Nursing Progress Note, dated 3/16/23, indicated that the resident was given Tylenol for mouth pain. A Nursing Progress Note, dated 3/21/2023, indicated the resident was given Tylenol at night for mouth pain. A Nursing Progress Note, dated 3/27/2023, indicted the resident had been receiving as needed Tylenol with 10 p.m. medications to help her mouth so she could sleep. A Nursing Progress Note, dated 4/14/23, indicated the resident requested ice cream or sherbet for her mouth. There was no documentation to indicate an oral assessment was completed, a dental consult was initiated, or the Physician had been notified. Interview with Social Services (SS) on 5/9/23 at 2:39 p.m., indicated she was not aware if the Nurse Practitioner (NP) had completed an oral assessment during her 2/13/23 appointment. The first time she was made aware the resident had mouth pain was by the Assistant Director of Nursing (ADON) on 5/1/23 or 5/2/23. SS was unable to provide any further documentation. Interview with the ADON on 5/9/23 at 2:39 p.m., indicated the resident complained about her gums somewhere between April 25th through 27th. She assessed the resident's gums and had not seen any concerns. The resident had told her she felt there was stuff coming out of her gums. She then told SS to set her up to see the dentist. She was unaware of any concerns the resident was having related to her gums prior to that. She was unable to provide any documentation related to completing an assessment of the resident's mouth. Interview with Director of Nursing (DON) on 5/9/23 at 3:00 p.m., indicated she was unable to provide any documentation the resident's gums had been assessed or that the NP was notified since 2/13/23. 3.1-24 (a)(2)

Based on record review and interview, the facility failed to monitor a medication's effectiveness related to a laboratory test not completed as ordered by the Physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 65) Finding includes: Resident 65's record was reviewed on 5/20/22 at 8:48 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Minimum Data Set assessment., dated 5/9/22 (after a hospitalization ), indicated the resident was severely cognitively impaired. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was ordered after a 4/16/22 Complete Blood Count (CBC) laboratory test indicated a low abnormal hemoglobin result. A CBC laboratory result, dated 4/27/22, indicated a low abnormal hemoglobin result of 7.2 (Normal range 12.4 to 14.9). The Physician indicated on this laboratory result report to complete a CBC, Comprehensive Metabolic Panel (CMP), iron panel and B-12 level laboratory test the next morning (4/28/22). The record lacked an indication the CBC, CMP, iron panel, and B-12 laboratory tests were completed as ordered on or after 4/28/22. A Care Plan was revised on 4/26/22, for potential tiredness, weakness and abnormal laboratory results due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, complete laboratory tests as ordered and to report abnormal values to the MD. Interview with the Director of Nursing on 5/20/22 at 2:02 p.m., indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to the incorrect administration of insulin for 2 of 6 residents observed during medication pass. (Residents 1 and 2) Finding includes: During a medication administration observation on 5/19/22 at 8:52 a.m. LPN 1 prepared Resident 1's medications which included insulin [MEDICATION(S)] ([MEDICATION(S)]). She took the insulin pen out of the medication cart and attached the needle. She then dialed the pen to 10 units and entered the resident's room. She donned gloves, cleaned the resident's right upper arm with an alcohol prep pad, and injected the insulin. She did not prime the insulin pen or perform an air shot prior to administering the insulin. Interview with LPN 1 on 5/19/22 at 9:01 a.m., indicated she had primed the insulin pen when it was new and first opened. She did not prime it prior to each injection because all the air pockets had already been removed when it was primed upon opening. LPN 1 then went on to prepare Resident 2's medications which also included insulin [MEDICATION(S)]. She took the insulin pen out of the medication cart and attached the needle. She then dialed the pen to 65 units and entered the resident's room. She donned gloves, cleaned the resident's right lower abdomen with an alcohol prep pad, and injected the insulin. She did not prime the insulin pen or perform an air shot prior to administering the insulin. Interview with LPN 1 on 5/19/22 at 9:05 a.m., indicated the insulin pen was not new so she did not have to prime it. Interview with the Director of Nursing (DON) on 5/19/22 at 10:53 a.m., indicated the insulin pens should have been primed prior to administration. Manufacturer's instructions for the [MEDICATION(S)] insulin pen, dated 3/2020 and provided by the DON, indicated, .Step 3. Perform a safety test. Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection .Step 4. Select the dose .Step 5. Inject your dose . 3.1-48(c)(2)

Based on observation, record review and interview, the facility failed to ensure a Physician's order was in place for a treatment being provided for 1 of 2 residents reviewed for [CONDITION(S)] and non-pressure skin conditions. (Resident 29) Finding includes: On 5/18/22 at 2:05 p.m., a treatment to Resident 29's left leg was observed with the Wound Nurse. The nurse removed the old dressing, washed the resident's leg with soap and water, applied [MEDICATION(S)] (skin moisturizer) and Webril (a cotton dressing), then wrapped the leg with Coban (an elastic type wrap). The resident's record was reviewed on 5/17/22 at 3:07 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 1/31/22, indicated to cleanse the left outer leg with soap and water, pat dry, then apply silver collagen (an antimicrobial dressing) to the wound bed, then apply triamcinolone ointment (a topical steroid) around the wound bed, apply Webril and wrap with Coban on Mondays, Wednesdays and Fridays. The May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The left leg had healed on 3/15/22. The record lacked an indication for a new Physician's Order for the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Wound Nurse on 5/18/22 at 2:20 p.m., indicated the resident had an arterial wound on her left leg that had healed on 3/14/22. The Physician's Order for the silver collagen and triamcinolone ointment had not been used since then, but the nurses would use that treatment if the area looked like it was going to open up again. She indicated there had not been an order in place for the new treatment. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure respiratory care was rendered as ordered related to incorrect oxygen flow rate, and unchanged humidification water bottle and oxygen tubing for 1 of 1 residents reviewed for respiratory care. (Resident 66) Finding includes: On 5/15/22 at 9:11 a.m., and 5/18/22 at 9:52 a.m., Resident 66 was observed seated in his room with his oxygen on. The oxygen concentrator was set on 3 liters per minute (lpm). The humidification water bottle and oxygen tubing was dated 5/11/22. The resident's record was reviewed on 5/18/22 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN 1 on 5/18/22 at 9:55 a.m., indicated the oxygen was set on 3 lpm, not 2 lpm as ordered. She adjusted the oxygen at that time. She also indicated the humidification bottle and tubing was dated 5/11/22, and had not been changed as signed out on the MAR. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure residents were free from abuse and neglect related to a resident to resident altercation and staff refusing to suction a resident as requested for 2 of 2 residents reviewed for abuse. (Residents 64 and 57) Findings include: 1. The record for Resident 64 was reviewed on 10/23/19 at 9:30 a.m. The resident was admitted on [DATE]. [DIAGNOSES REDACTED]. The MDS quarterly assessment Brief Interview for Mental Status (BIMS), dated 10/8/19, indicated she was cognitively intact. During an interview with the resident on 10/21/19 at 11:37 a.m., she indicated another resident had slapped her on the face approximately one month ago in the dining room. Staff was present and had intervened immediately. The Incident Report indicated, on 9/2/19 at 2:20 p.m., a male resident approached Resident 64 in the dining room during Bingo and was attempting to communicate with her. She was unable to understand the male resident and had asked a staff member for assistance; staff assisted the male resident back to the nurses station. Between 2:10 and 2:20 p.m. the male returned to the dining room and approached Resident 64, and slapped her open handed in the face. A witness statement written by Activity Aide 1, dated 9/2/19, indicated the male resident had returned back to the dining room at 2:10 p.m. and headed straight for Resident 64 and slapped her open handed in the mouth. The activity aide immediately removed the resident from the area and notified the nurse. 2. Interview with Resident 57 on 10/23/19 at 8:09 a.m., indicated the Midnight nurse who had worked last night refused to suction her tracheotomy after she had asked. Resident 57 indicated she was told to cough it up. She indicated this was not the first time she was refused to be suctioned by this nurse. Interview with Resident 57 on 10/25/19 at 2:50 p.m., indicated the Midnight nurse refused to suction her this past Monday early morning. The Midnight nurse told her to cough it up and, after she indicated that she could not cough it up, the nurse told her to just keep trying. Resident 57 indicated that had upset her and she did not turn her call light on after that when she needed to be suctioned again. The incident was reported to the Administrator immediately after interviewing the resident. A report was sent to ISDH (Indiana State Department of Health) and an investigation was started. The Midnight nurse accused of not suctioning a resident with a tracheotomy was suspended until the investigation was completed. Resident 57's record was reviewed on 10/23/19 at 9:45 a.m. [DIAGNOSES REDACTED]. anxiety and depression. The Midnight nurse, RN 2 was interviewed by the Administrator (not dated). RN 2 indicated on Monday morning at approximately 3:45 a.m., it was reported to her by a CNA that Resident 57 couldn't breathe and wanted to be suctioned. RN 2 assessed the resident and the following was observed: fingernails were pinkish, lung sounds clear but diminished per her norm, respirations were slow and even, lips were pink, and after she removed the blanket from over her head, she was educated on the futility of suctioning when she did not wear the humidity and that when secretion are thick, they can not be suctioned. Per the on going investigation, CNA 2 was interviewed on 10/24/19 (the time was not indicated). She indicated on 10/25/19, she had witnessed RN 2 tell Resident 57 that she could not be suctioned because her tracheotomy was too dry. The record lacked documentation of any assessment of the resident completed by RN 2 per the interview. RN 2 was called to be interviewed on 10/25/19 at 2:40 p.m. She did not answer the phone. CNA 2 was called to be interviewed on 10/25/19 at 2:45 p.m. She did not answer the phone. Interview with the Director of Nursing on 10/25/19 at 3:18 p.m., indicated it was her expectations of the Nurses to assess the resident, listen to lung sounds, ask the resident to try to cough up the secretions, check respirations, oxygen saturations, educate the resident on the resident on increase risk of infection and suction them to keep them comfortable. The resident should never be refused to be suctioned. Interview with the Administrator on 10/25/19 at 2:15 p.m., the investigation was not complete and at that time, RN 2 was still suspended. 3.1-27 (a)(b)

Based on record review and interview, the facility failed to monitor two residents (Residents #B and #C) who were receiving [MEDICATION NAME] ([MEDICATION NAME]) (blood thinners), PT's (pro-time) and INR's (international normalized ratio) (laboratory blood clotting test) as ordered by the Physician. Resident #B was admitted into the hospital with the [DIAGNOSES REDACTED].#C) required vitamin K treatment, for 2 of 3 residents reviewed for blood thinners in a total sample of 3. The facility also failed to monitor for signs and symptoms of bleeding related to the usage of blood thinners for 1 of 3 residents in a sample of 3 (Resident #C) and 2 of 4 in an extended sample of 4. (Residents #F and #G) The immediate jeopardy began on 01/15/16 when the facility failed to monitor a PT/INR on a resident (Resident #B) on [MEDICATION NAME] and [MEDICATION NAME] (also thins blood) as ordered by the Physician. This resulted in the Resident #B being admitted to the hospital with [REDACTED]. Resident #B required a blood transfusion and Resident #C required Vitamin K for a critical PT of 129.6 and critical INR of 10.6. The Administrator and Director of Nursing were notified of the immediate jeopardy at 1:10 p.m. on 02/05/16. The immediate jeopardy was removed on 02/08/16, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During the initial tour of the facility on 02/04/16 at 1:30 p.m., LPN Unit Manager #1 indicated Resident #B was in the hospital due to an abnormal PT and INR, and the resident had bruising prior to being transferred to the hospital. Resident #B's record was reviewed on 02/04/16 at 2:10 p.m. The resident's [DIAGNOSES REDACTED]. The resident had been admitted to the facility on [DATE]. A care plan, dated 01/18/16, indicated the resident was at risk for abnormal/excessive bleeding due to the use of anticoagulant (blood thinner) medication, [MEDICATION NAME] and [MEDICATION NAME]. The interventions included to complete lab tests as ordered. The pre-admission PT/INR from the hospital, dated 01/14/16, indicated a PT of 16.2 (normal 8.4-12/9) and INR of 1.41 (normal 0.72-1.11) (therapeutic INR 2.0-3.0) The Hospital admission orders [REDACTED]dose accordingly. The orders indicated the resident received 5 mg of [MEDICATION NAME] on 01/13/16 at 6 p.m. The facility's electronically transcribed physician's orders [REDACTED]. The Medication Administration Record, [REDACTED]. A Physician's Progress Note, dated 01/24/16, indicated, .continue [MEDICATION NAME] management by [MEDICATION NAME] Clinic (clinic which doses the [MEDICATION NAME] by the PT/INR results) . A physician's orders [REDACTED]. There were no orders to indicate the facility received an order to monitor the INR after the Admission Order of 01/15/16. There were no orders to indicated the [MEDICATION NAME] Clinic had been notified of the need to manage the [MEDICATION NAME] therapy. The Nurses' Progress Notes, dated 01/28/16 at 10:43 p.m., 01/29/16 at 6:54 p.m., 01/31/16 at 1:49 p.m., and 02/01/16 at 10:24 a.m., indicated the resident was complaining of pain in the right knee and leg area. The Nurses' Progress Notes, indicated: 02/01/16 at 3:31 p.m., Call to (Physician Name) .re: therapy request of MRI for Right hip . 02/01/16 at 8:48 p.m., New orders received .D/C [MEDICATION NAME] if INR greater than 2.0 when PT/INR is drawn on 02/04/16 . 02/02/16 at 8:48 a.m., During assessment of skin this morning, resident was noted to have a purple bruise on her right outer hip/thigh area and a purple bruise behind her right knee. Resident stated she did not know how it had happened . 02/02/16 at 8:55 a.m., .c/o severe pain in right leg, thigh area, noted to have bruise on right thigh this a.m., Notified (Physician's Name) .order to transfer to ER for eval (evaluation) and treat . A New Skin Event, dated 02/02/16 at 9:09 a.m., indicated the bruise behind the right knee was 5.5 centimeters (cm) by 1.5 cm. A New Skin Event, dated 02/02/16 at 9:06 a.m., indicated the bruise on the right outer hip/thigh was 23.5 cm by 8 cm. The Hospital emergency room physician progress notes [REDACTED].Right hip pain Onset: 1 week Timing: constant .Quality: pain, bruising, Severity: moderate .PT (patient) states she noticed bruising to the area yesterday. She has had XR (x-ray) .no fx (fracture) .will do CT scan. I think likely she has had some remote trauma and with her being on [MEDICATION NAME] and [MEDICATION NAME] she has marked ecchymosis (bruising) and probably some bleeding . RBC (red blood cells) 2.38 (normal 3.8-5.7), hgb (hemoglobin) (carries oxygen in the blood) 7.2 (normal 12-15), HCT (hematacrit) (volume percentage of red blood cells) (Normal 35-49) . PT 128.6 sec (seconds) HI, INR 11.69 CRIT (critical) .CT lower extremity IMPRESSION: 1. Acute intramuscular hematomas expanding the gluteus minimus and vastus lateralis (hip and buttock area) .12:07 (p.m.) .blood transfusion is ready to be started .Impression and Plan 1. Acute intramuscular hematomas to right gluteus and right thigh 1. Sever [MEDICATION NAME] toxicity 3. Small abdominal wall hematomas 4. Significant [MEDICAL CONDITION] secondary to #1, #2, and #3 .Calls-Consults .she need to go to (Hospital Name) where orthopedics and general surgery is available just in case [DIAGNOSES REDACTED] develops (increased pressure in the muscles and nerves) or got worse .go ahead and give her Vitamin K .and blood transfusion . A Hospital Admission History and Physical, dated 02/02/16 at 8:11 p.m., indicated, .in the emergency department, workup showed that her INR was 11.69. Her last INR was on the day of discharge (01/14/16), which was 1.41. Her hemoglobin was also noticed dropping from 10.7 to 7.2 .the patient was given 2 fresh frozen plasma and IV (intravenous) vitamin K .Assessment: .1. Right thigh hematoma, secondary to supratherapeutic INR 2. Supratherapeutic INR and the patient is also on full-dose [MEDICATION NAME] 3. Dehydration 4. Acute [MEDICAL CONDITION], due to above .Plan: 1. At this point of time, considering the condition of the patient is guarded .my biggest concern is [DIAGNOSES REDACTED] .At this point in time, the thigh area is very tight, but peripheral circulation is intact .will closely monitor her hemoglobin .As far as acute [MEDICAL CONDITION] is concerned, which is secondary to right thigh hematoma, I will closely monitor her hemoglobin . During an interview on 02/04/16 at 4:30 p.m., the Director of Nursing (DoN) indicated the PT/INR was not completed on 01/15/16 as ordered by the Physician. The DoN indicated the Admitting Nurse had not seen the order on the discharge instructions from the hospital. The DoN indicated an audit was completed on the admission 24 hours after admission and the second Nurse had also missed the PT/INR orders. 2. Resident #C's record was reviewed on 02/05/16 at 8:30 a.m. The resident's [DIAGNOSES REDACTED]. A care plan, dated 01/15/16, indicated the resident was at risk for abnormal/excessive bleeding due to anticoagulant medication use. The interventions included, labs as ordered. A physician's orders [REDACTED]. A [MEDICATION NAME] Clinic Fax Form, dated 01/27/16, indicated the resident's PT was 32 and INR was 2.8 and the order was to administer 2 mg of [MEDICATION NAME] daily and recheck the INR on 02/01/16. A physician's orders [REDACTED]. The Medication Administration Records, dated 01/2016 and 02/2016, indicated the resident received [MEDICATION NAME] 2 mg at 5 p.m. on January 27-31, 2016 and February 1, 2016. A [MEDICATION NAME] Clinic Fax Form, dated 02/01/16, indicated the PT/INR was missed on 02/01/16, [MEDICATION NAME] orders were for 2 mg daily, and to recheck the INR on 2/2/16 because the INR was missed on 02/01/16. A PT/INR result, dated 02/02/16, indicated the PT was 129.6, critical high and the INR was 10.6, critical high. A [MEDICATION NAME] Clinic Fax Form, dated 02/02/16, indicated to hold the [MEDICATION NAME], give Vitamin K 2.5 mg, monitor for safety and bleeding, and to notify the Physician if any bleeding occurs. The Medication Administration Record, [REDACTED]. There were no Nurses' Progress notes on 02/02/16 to indicate the resident had been monitored for signs of symptoms of bleeding. The Nurses' Progress Notes indicated: 02/01/16 at 10:43 p.m. .Abrasion to left lower back with scattered bruising observed . (Resident with fall on 01/29/16) 02/03/16 at 3:42 a.m., .Drs (dressing) to left hip changed, moderate amount of sanguineous drainage (contains blood) noted . 02/03/16 at 2:28 p.m., Drsg (dressing) changed to left hip, small amount bloody drng (drainage) on old drsg. surrounding skin bruised .hip is protruding and hard, possible hematoma .(Orthopedic Physician Name) notified . 02/04/16 at 9:50 a.m., indicated the Orthopedic Physician wanted to see the resident at the office. The Orthopedic Physician's Progress Note, dated 02/04/16, indicated the resident had a large hematoma on the left hip. During an interview on 02/05/16 at 9:55 a.m., the DoN indicated the facility had found in an audit the PT/INR lab draw was missed on 02/01/16. The DoN indicated she had not investigated why the PT/INR had not been obtained. The DoN indicated the order looked like it had been written but not put into the computer system to alert the Lab Company. The DoN indicated the error was found on 02/02/16 and thought it was just a transcription error on the date and the lab was due on 02/02/16 not 02/01/16. The DoN indicated she had not seen the missed on the [MEDICATION NAME] Clinic Form. The DoN indicated there were no assessments of signs and symptoms of bleeding. 3. Resident #F's record was reviewed on 02/05/16 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The Medication Administration Record [REDACTED]. A [MEDICATION NAME] Clinic Fax Form, dated 01/19/16, indicated the resident's INR (clotting time) was 3.0 (normal 0.72-1.11) (therapeutic INR 2.0-3.0), give [MEDICATION NAME] 1.25 mg on 01/19/16, and recheck the resident's INR on 01/20/16. The [MEDICATION NAME] 1.25 mg had not been transcribed onto the MAR indicated [REDACTED]. A [MEDICATION NAME] Clinic Fax Form, dated 01/20/16, indicated the resident's INR was 5.5 (high). The order was to hold the [MEDICATION NAME] on January 20 and 21, 2016. There was no documentation in the Nurses' Progress Notes or the MAR indicated [REDACTED]. 4. Resident #G's record was reviewed on 02/05/16 at 2:15 p.m. The resident's [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The MAR, dated 01/06/16 through 02/05/16, indicated no [MEDICATION NAME] had been given on 01/27/16. The MAR indicated [REDACTED] A [MEDICATION NAME] Clinic Fax Form, dated 01/28/16, indicated the resident's INR was 1.5, begin [MEDICATION NAME] 7 mg, and recheck the INR on 01/29/16. The MAR, dated 01/06/16 through 02/05/16, indicated no [MEDICATION NAME] had been administered on 01/28/16. The MAR indicated [REDACTED] There was no documentation in the Nurses' Progress Notes or the MAR indicated [REDACTED]. During an interview with the DoN on 02/05/16 at 4 p.m., she indicated the Nurses' had not completed assessments for signs and symptoms of bleeding. A facility policy, dated 01/2016, titled, [MEDICATION NAME]/[MEDICATION NAME] Monitoring, received from the DoN as the policy in place prior to the occurrence on 01/15/16, indicated, .Orders of lab testing will be obtained per physician order [REDACTED]. The immediate jeopardy that began on 01/15/16 was removed on 02/08/16 when the facility revised the procedure for obtaining and transcribing physician's orders [REDACTED]. The facility initiated lab tracking logs to ensure all PT/INR's were completed as ordered and inservices were completed on 28 of the 30 Nurses' and QMA's of the revised policy and procedures. The DoN indicated all other Nurses' and Nurses' just hired will be inserviced. Interview with the Nurses' indicated they were inserviced and knowledgeable of the revisions to the policy and procedures. Residents who had PT/INR's orders, had the lab completed and medication adjustments were initiated. A New Admission was reviewed, the resident was on [MEDICATION NAME], orders were obtained for PT/INR's, and the [MEDICATION NAME] Clinic was notified, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Federal Tag relates to complaint IN 802. 3.1-48(a)(3) 3.1-48(a)(5)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents, related to a pressure alarm not being on a resident as ordered and care planned, The resident stood from the wheelchair, fell and received a laceration to the forehead and a dislocated finger, for 1 of 3 residents reviewed for falls in a total sample of 4. (Resident #E) Findings include: Resident #E's record was reviewed on 01/21/15 at 1 p.m. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 12/04/14, indicated the resident's cognition was intact, required extensive assistance for transfers, and had a history of [REDACTED]. A care plan, dated 09/02/14, indicated the resident was a fall risk and had a history of [REDACTED]. A physician's orders [REDACTED]. A Nurses' Progress Note, dated 01/03/15 at 2:59 p.m., indicated the resident had been sitting in the dining room watching TV, when he attempted to stand from the wheelchair, without assistance and fell . The resident received a cut to the center of the forehead which was approximately, "1.5 inches" and complained of severe pain to the right shoulder, hip, and elbow. The resident was immediately transferred to the hospital emergency room . A Nurses' Progress Note, dated 01/03/15 at 6:36 p.m., indicated the resident returned to the facility from the emergency room . The report from the hospital indicated the cut to the head had been glued and the resident had a dislocated finger, which had been reduced and now had a splint on the right ring finger. The emergency room transfer papers, dated 01/03/15 at 4:49 p.m., indicated the resident had a dislocated finger, which was reduced (aligned) and would take about six weeks for the ligaments to heal. The Progress Notes, indicated the resident's right ring finger had swelling and bruising and the resident had a 1 centimeter laceration to the forehead with mild amount of swelling. The facility's Interdisciplinary Team Notes, dated 01/05/15 at 10:15 a.m., indicated the resident attempted to stand up with assistance and fell , which resulted in a cut to the forehead and complaints of sever pain to his right shoulder, right hip, and right elbow. The note indicated the resident returned from the emergency room with a skin tear to the head, which was glued back together and a splint to the right ring finger for the dislocation. The note indicated the facility would use a pull pin alarm while the resident was in the wheelchair instead of a pressure sensor alarm. The Fall Investigation, received from the Director of Nursing, dated 01/03/15, indicated, "...Where was the last place you saw resident before the fall occurred...Sitting in w/c (wheelchair) in dining room @ (at) table watching TV et eating watermelon. Did you witness the fall? No...Were all care planned or ordered interventions in place? Res (resident) in 1W (West) D/R (dining room), w/in (within) view of all staff @ Nurses' Station, Res stood and fell before staff could assist...Per nursing documentation, w/c alarm was not sounding at time of fall..." During an interview on 01/21/15 at 2:45 p.m., the Director of Nursing (DoN) indicated the Nurse on Duty at the time of the fall (LPN #1) had not heard the wheelchair alarm sound. The DoN indicated the alarm was not on at the time of the resident's fall, then continued to indicate the alarm was not in place at the time of the fall. The DoN indicated the LPN #1 was inserviced about the alarm placement. During an interview on 01/21/15 at 3:40 p.m., LPN #1 indicated she could not recall if the pressure alarm was on at the time of the fall. She indicated there was no alarm activated. She indicated the resident was in view of the staff at all times and the staff could not get to the resident quick enough to prevent the fall. LPN #1 indicated there was no alarm sounded at the time of the fall. This Federal Tag relates to complaint IN 172. 3.1-45(a)(2)

Based on record review, observation and interview, the facility failed to ensure residents received supervision and assistance to prevent accidents, related to leaving residents who were at risk for falls in the bathroom without supervision and the residents fell , which resulted in a fractured left hip for one resident and a fractured arm and bruising of the face for one resident (Residents #C and #D) and transferring a resident, who required 2 assistants for transfers with only 1 assistant, (Resident #B) for 3 of 3 residents reviewed for falls in a total sample of 4. Findings include: 1. Resident #C's record was reviewed on 03/17/14 at 12:30 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired, required extensive assistance of one for transfers, and was unable to steady self with standing and transfers without the help of staff. The Care Plan, dated 10/23/13, indicated the resident was a risk for falls, required assistance with transfers, and had poor decision making skills. The interventions included, (07/30/13) pressure alarm to the chair to alert staff of attempts to transfer without assistance and do not leave the resident unattended while toileting. A physician's orders [REDACTED]. The Nurses' Progress Notes indicated: 02/12/14 at 6:40 a.m.-"staff assisted resident to the bathroom and then back to bed. Gait is extremely unsteady..." 02/12/14 at 10:09 a.m.-"Gait continued to be unsteady this morning..." 02/13/14 at 5 a.m.-"Resident's bed pressure alarm sounded and CNA entered resident's room. Resident was standing with her walker and fell back onto her buttocks onto her roommate's blue mat. CNA could not get to her in time of fall...Resident was wanting to go to the bathroom...Denies pain..." 02/24/14 at 7:58 a.m.-"Resdinet (sic) was assisted to the restroom with 1 staff, staff memebr (sic) went to her wardrobe to get her clothes for the day, resdinet (sic) stood from toilet and fell on the floor, hitting her head on the toilet...send residnet (sic) to ER..." 02/27/14 at 7:17 p.m.-"Resident arrived to facility (return from hospital)...Edema noted to (l) (left) leg...3 bandages to L hip/leg from surgery...Numerous bruising noted throughout body..." 03/01/14 at 2 a.m.- "Ten staples noted to left hip area. Seven staples to left mid thigh area. Three staples noted to area above the left knee. Bruising to left hip and left thigh..." An Admission Note from the hospital, dated 02/24/14, indicated the resident had comminuted intertrochanteric fracture of the left proximal femur (hip fracture). A fall investigation, dated 02/24/14, indicated the resident was in the bathroom and had attempted to transfer herself off the toilet without assistance, was not able to transfer self and fell . The investigation indicated the environment was checked for safety hazards and none were found. During an interview on 03/17/14 at 2:20 p.m., the Director of Nursing (DoN) indicated the resident should not have been left alone in the bathroom. 2. Resident #D's record was reviewed on 03/17/14 at 10:45 a.m. The resident's [DIAGNOSES REDACTED]., The Quarterly MDS assessment dated [DATE], indicated the resident had moderately impaired cognition, required extensive assistance of two or more for transfers and toileting, and was unsteady without staff assistance while standing. The Fall Risk assessment dated [DATE] at 11:49 a.m., indicated Resident #D was at risk for falls. The care plan dated 05/03/13 indicated Resident #D was at risk for falls. The interventions included, not to leave the resident in the bathroom unattended while being toileted. The 03/14/14 Nurse's Note at 2:46 p.m. indicated Resident #D was assisted to the toilet by a CNA. The resident then attempted to transfer herself, unassisted, and fell trying to get back into wheelchair. The resident received multiple abrasions to the face, a cut with noted blood to the forehead, and the resident was transferred to the emergency room . On 03/14/14, the hospital "After Visit Summary" indicated, Resident #D had a right humerus closed fracture and was treated with immobilization. Discharge instructions also indicated the resident had a concussion or a closed head injury. A fall investigation, dated 03/14/14, indicated the staff heard Resident #D yelling for help. Resident #D was found on the bathroom floor injured and was transferred to the emergency room . On 03/17/14 at 1:30 p.m. Resident #D was observed sitting in wheelchair, with her right arm in sling and multiple dark green, red and purple brushing to resident's face. During an interview on 03/14/14 at 3:04 p.m., the DoN indicated the resident was left unattended in the bathroom. She indicated staff should have stayed with the resident. 3. Resident #B's record was reviewed on 03/17/14 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The Admission MDS Assessment, dated 01/16/14, indicated the resident had no cognition impairment, required extensive assistance of 2 or more for transfers, was unable to balance self with standing without help, and had a history of [REDACTED]. A Care Plan, dated 01/10/14, indicated the resident was at risk for falls due to general weakness and expressed a fear of falling. The interventions included to use two assistants for transfers. A Physical Therapy Plan of Care, dated 01/10/14 to 02/08/14, indicated the resident required maximum assistance of two (two people) for transfers from bed to chair. An Event Report, dated 02/01/14 at 2:31 p.m., indicated, "...CMA was transferring res. (resident) to recliner, her legs became weak, she leaned on CNA, and CNA lowered her to the floor..." A Nurses' Progress Note, dated 02/03/14 at 10:08 a.m., the resident complained of severe pain in the left leg, bilateral shoulders, and back. The note stated the resident requested to go to the hospital and the Physician was notified and an order was received to transfer the resident to the emergency room . A fall investigation, dated 02/04/14, indicated one CNA had placed a gait belt on the resident and had attempted to transfer the resident with only one assistant. The investigation indicated the CNA had attempted to get the resident to sit back in the wheelchair when the resident leaned on the CNA, pushing the CNA and the CNA then lowered the resident to the floor. The resident sat on the floor with the left leg tucked under her right leg. The CNA then went to get the nurse. The resident then attempted to get herself towards the bed and indicated she could get herself into the bed. Two nurses and one CNA attempted to get the resident off the floor and could not. Three nurses and three CNA's were able to lift the resident back into her wheelchair. No concerns were voiced from the resident. The emergency room physician progress notes [REDACTED]. The note indicated the resident had informed the Physician that when the nurses attempted to get her off the floor they had dropped her, causing the pain to increase. The hospital Discharge Summary, dated 02/07/14, indicated the resident had a large left knee effusion and partial quadriceps muscle tear and would require a left knee immobilize. During an interview on 03/17/14, the DoN indicated there were not two CNA's used to transfer the resident, only one CNA attempted the transfer and she had used the gait belt. This Federal Tag relates to complaint IN 208. 3.1-45(a)(1) 3.1-45(a)(2)

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE RESIDENTS REMAINED FREE FROM ABUSE AS EVIDENCED BY THE FAILURE OF THE FACILITY TO IDENTIFY ABUSE, REPORT ABUSE, THOROUGHLY INVESTIGATE REPORTS OF ABUSE, EDUCATE STAFF ON THE FACILITY ABUSE PROTOCOL, IMPLEMENT THE FACILITY ABUSE POLICY, AND PUT SAFEGUARDS IN PLACE FOR RESIDENTS. THIS DEFICIENT PRACTICE DIRECTLY AFFECTED 4 RESIDENTS IN A SAMPLE OF 24 RESIDENTS AND 7 RESIDENTS IN A SUPPLEMENTAL SAMPLE OF 30 RESIDENTS. THIS DEFICIENT PRACTICE HAD THE POTENTIAL TO AFFECT 116 OF 116 RESIDENTS RESIDING IN THE CERTIFIED UNITS OF THE BUILDING. (RESIDENTS # 118, # 68, # 52, # 34, # 62, # 12, # 119, # 84, # 27, # 17, AND # 19) (CERTIFIED NURSING AIDES # 1, # 2, # 6, # 7, # 9, AND # 10) (LICENSED PRACTICAL NURSES # 4, # 5, AND # 8) (UNIT MANAGER # 3) (DIETARY MANAGER) (STAFF DEVELOPMENT COORDINATOR) THIS DEFICIENT PRACTICE RESULTED IN AN IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/29/10 AND BEGAN ON 10/13/10. THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/29/10. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/1/10, BUT THE FACILITY REMAINED OUT OF COMPLIANCE AT THE LEVEL OF AN ISOLATED INSTANCE OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM BECAUSE OF THE CONTINUED NEED FOR FOLLOW-UP RELATED TO ABUSE ALLEGATIONS, INSERVICING FOR NEW STAFF, AND ONGOING MONITORING OF ABUSE IN THE FACILITY. FINDINGS INCLUDE: 1. REVIEW OF A "FAX INCIDENT REPORTING FORM", ON 10/28/10 AT 12:30 A.M., INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS THE INITIAL REPORT OF THE INCIDENT. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "ON EVENING ROUNDS A CNA REPORTED THAT CNA # 1 WAS USING PROFANITY AND PROVIDING ROUGH CARE TO RESIDENTS." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." REVIEW OF A "FAX INCIDENT REPORTING FORM", INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS A 5 DAY FOLLOW-UP TO THE INCIDENT PREVIOUSLY REPORTED. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "REPORTED THAT (NAME OF CNA # 1) USED PROFANITY (AND) WAS ROUGH WHILE PROVIDING CARE TO RESIDENT." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION. ASSESSED RES (RESIDENTS) FOR INJURIES. NONE FOUND. SS (SOCIAL SERVICES) INTERVIEWED ALERT RESIDENTS ON THE UNIT. OTHER STAFF WERE INTERVIEWED." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER (NAME OF CNA # 1) HAS BEEN TERMINATED." REVIEW OF AN "ABUSE FLOW RECORD" FORM, INDICATED THE NATURE OF THE EVENT WAS ALLEGED VERBAL ABUSE. THE FORM INDICATED THE DATE OF THE EVENT WAS 10/13/10 FROM 9:00 P.M.-11:00 P.M., AND THE LOCATION OF THE EVENT WAS THE 1 WEST UNIT. THE EVENT WAS REPORTED TO THE ADMINISTRATOR/DESIGNEE ON 10/14/10 AT 5:25 P.M. THE EVENT WAS REPORTED BY CNA # 2. THE INDIVIDUAL SUSPENDED PENDING THE INVESTIGATION WAS CNA # 1, AND SHE WAS SUSPENDED ON 10/14/10. THE FORM INDICATED THE STAFF INTERVIEWED DURING THE INVESTIGATION PERIOD WERE RN # 3, LPN # 4, AND LPN # 5. THE FORM INDICATED RESIDENTS # 52, # 69, AND # 34 WERE INTERVIEWED DURING THE INVESTIGATION PERIOD. A NARRATIVE STATEMENT ON THE FORM INDICATED "STAFF REPORT EMPLOYEE GOES TO FAST (WITH) CARE. HAS BEEN COUNSELED TO SLOW DOWN. RES (RESIDENTS) WOULD NOT VERIFY ROUGH TREATMENT ON 10/15/10, BUT HAD STATED TO (INITIALS OF LPN # 5) BEFORE. EMPLOYEE LET GO D/T (DUE TO) CONTINUED POOR PERFORMANCE." THERE WERE NO SIGNATURES ON THE FORM TO INDICATE WHO COMPLETED THE "ABUSE FLOW RECORD" FORM. THERE WERE NO STAFF OR RESIDENT INTERVIEWS DOCUMENTED ON THE FORM, AND THERE WAS NO DOCUMENTATION TO INDICATE THE PHYSICIAN OR FAMILIES OF THE RESIDENTS INVOLVED WERE NOTIFIED. A HANDWRITTEN STATEMENT BY CNA # 2, DATED 10/14/10 AT 5:25 P.M., WAS THE INITIAL REPORT OF THE VERBAL AND PHYSICAL ABUSE WHICH OCCURED ON 10/13/10. THE STATEMENT INDICATED, "... DATED OF INCIDENT: 10/13/10 9 P (9:00 P.M.)-11 P (11:00 P.M.) DATE OF STATEMENT: 10/14/10 5:25 P.M. ... I WAS WORKING 1 WEST WITH (NAME OF CNA # 1) FIRST TIME WORKING 1 WEST AND FIRST TIME WORKING WITH HER. AT FIRST IT WAS GOING WELL SHE SHOWERED (NAME OF RESIDENT # 19) AND WAS REALLY NICE TO HER. WHEN IT CAME TO ROUNDS THE LAST ONE OF THE NIGHT WE STARTED ABOUT 10:00 P.M. THE FIRST FEW ROOMS (NAME OF CNA # 1) WAS CURSING SAYING 'F--- THIS S---' AND 'I HATE THIS (SIC) F---ING PEOPLE' I WAS SHOCKED BUT I MOVED ON TO THE NEXT RESIDENT BECAUSE I DIDN'T WANT TO FEED THE FIRE. WELL WE GOT TO (INITIAL) AND SHE WAS WET AND TAKING OFF HER GOWN. (NAME OF CNA # 1) WALKED IN TELLING HER TO 'KEEP HER F---ING CLOTHS (SIC) ON.' WHEN WE WERE CHANGING HER BED WE HAD TO DO A COMPLETE BED CHANGE (NAME OF CNA # 1) GATHERED THE LINEN WHILE I HELPED RESIDENT TAKE HER GOWN THE REST OF THE WAY OFF. (NAME OF CNA # 1) TOLD RESIDENT TO 'ROLL THE F--- OVER.' BUT THE RESIDENT COULDN'T DO TASK ON HER OWN SO (NAME OF CNA # 1) GOT MAD SAYING SHE 'HATED THIS FAT COW' CALLED HER A 'B----' MULTIPUL (SIC) OVER AND OVER SHOVING HER REALLY HARD I FELT SO BAD I TOLD (NAME OF CNA # 1) AFTER WE HAD THE BOTTOM SHEET ON i WOULD FINISH. SHE THREW THE BLANKETS ON HER BARELY COVRING (SIC) THE RESIDENT AND SAID THAT'S (SIC) GOOD I IGNORED THE STATEMENT AND FINISHED PUTTING ON RESIDENT CLEAN GOWN. (NAME OF CNA # 1) LEFT THE ROOM AND RESIDENT SAID SHE DIDN'T LIKE HER SHE WAS MEAN. RESIDENT WAS BARELY ABLE TO TALK BUT THAT'S (SIC) WHAT I GOT OUT OF WHAT SHE WAS SAYING. THEN AFTER THIS WE WENT ON WITH OUR ROUND AND WE GOT TO (NAME OF RESIDENT # 68) WHEN I WALKED IN ROOM (NAME OF CNA # 1) WAS RIPPING OFF THE BLANKETS WITH HER RIGHT ARM THROWING THEM ON THE FLOOR. LITERALLY RIPPED THEM FROM HIM. SHE SAID 'I HATE THIS MAN' RIGHT IN HIS FACE. THEN CHANGED HIS PADS SHOVING HIM FROM SIDE TO SIDE LIKE A RAG DOLE (SIC). HE BECAME COMBATIVE BY NOW TELLING HER TO LEAVE HIM ALONE. SHE SAID 'I WISH YOU WOULD JUST DIE.' AT THIS TIME SHE WAS TAKING THE BLANKETS AND DIRTY LAUNDRY OUT OF THE ROOM. I TRIED CALMING HIM DOWN AS I PUT HIS GOWN ON. I SAID "I'M SORRY AND SMILED AT HIM AND HE INSTANTLY CALMED DOWN, AND SMILED BACK. I COVERED HIM WITH A NEW SHEET AND BLANKET. AFTER THIS WE WENT INTO ANOTHER LADIES ROOM I CAN'T REMEMBER HER NAME, AND SHE HAD THROWN UP GREEN STUFF EVERYWHERE. (NAME OF CNA # 1) TURNED AND LOOKED OUT AT ME ASKING 'HOW THE NIGHT COULD GET ANY WORSE.' SHE CURSED SOME MORE I KINDA (SIC) STARTED IGNORING HER AT THIS POINT. BUT THIS IS THE ROOM THE NURSE (LPN # 4) CAME IN DURING (NAME OF CNA # 1) CURSING SHE DIDN'T SAY ANYTHING EXCEPT YOU SHOULD HAVE STARTED EARLIER. THEN LEFT. THIS WAS THE END OF THE BAD ATTITUDE AND VERBAL ABUSE THAT I WITNESSED." THE HANDWRITTEN STATEMENT WAS SIGNED BY CNA # 2. THE INVESTIGATION INTO THE INCIDENT ON 10/13/10 INCLUDED A HANDWRITTEN NURSING NOTE, WRITTEN BY LPN # 5. THE NOTE INDICATED "REFERENCE TO CNA: (NAME OF CNA # 1) RECEIVED COMPLAINTS FROM FOLLOWING RESIDENTS REGARDING RESIDENT CARE: 1. (NAME OF RESIDENT # 52); WHEN (NAME OF RESIDENT # 62) WAS ILL (AND) CONFUSED (RESIDENT NAME) STATED SHE TALKED MEAN TO HER (AND) WAS ROUGH (WITH) HER WHILE TRANSFERRING HER INTO BED. 2. (NAME OF RESIDENT # 34) COMPLAINED ABOUT WHEN CARING FOR (NAME OF RESIDENT # 12) (AND) (NAME OF RESIDENT # 119) THAT SHE WAS ROUGH DURING CARE. 3. (NAME OF RESIDENT # 84) COMPLAINT OF HER BE ROUGH (WITH) HER TO ANOTHER CNA (NAME OF CNA # 6) THAT SHE CAUSED HE (SIC) SKIN TEAR TO ARM BY PUSHING HER THROUGH THE DOOR. - (NAME OF RESIDENT # 84) REQUESTS SHE NOT CARE TO HER NEEDS IF POSSIBLE. 4. (NAME OF RESIDENT # 27) AFTER PUTTING HER TO BED 2 DIFFERENT TIMES (NAME OF RESIDENT # 27) WAS CRYING (AND) TOLD CNAS (NAME OF CNA # 6 AND NAME OF CNA # 7) SHE WAS ROUGH (WITH) HER. 5. (NAME OF RESIDENT # 27) TOLD ME SHE JERKS (NAME OF RESIDENT # 17) AROUND WHEN CARING FOR HER. 6. IN THE MAIN DR (DINING ROOM) SHE WAS FEEDING (NAME OF RESIDENT # 68)--(PER LPN # 8 AND CNA # 6) (NAME OF RESIDENT # 68) KEPT TELLING HER 'NO' WHEN SHE WAS FEEDING HIM (AND) SHE CONTINUED TO PUT FOOD IN HIS MOUTH (NAME OF LPN # 8) TOLD HER THAT WAS FORCE FEEDING. (NAME OF CNA # 1) STATED 'IT WASN'T' (NAME OF DIETARY MANAGER) ALSO WITNESSED THIS (AND) STATED TO (NAME OF LPN # 8) SHE WOULD REPORT INCIDENT IN AM MEETING. 7. (NAME OF RESIDENT # 19) COMPLAINED SHE WAS JERKING HER ARMS. ((NAME OF RESIDENT # 19) COMPLAINED TO ME) WHEN TRANSFER HER. WITNESSED BY (NAME OF CNA # 6). (NAME OF CNA # 1) DENIED. ANYTIME (NAME OF CNA # 1) HAS BEEN QUESTIONED ABOUT ROUGHNESS OR FORCE FEEDING SHE DENIES. I HAVE NOT WITNESSED ABUSE BY HER BUT RESIDENTS COMPLAIN (AND) REQUEST ANOTHER AIDE. HAVE TALKED TO (NAME OF CNA # 1) (AND) ASKED HER TO SLOW DOWN DURING CARE OF RESIDENTS (AND) TAKE HER TIME (AND) NOT RUSH.--(NAME OF CNA # 1) DENIES BEING ROUGH.--I BELIEVE THE RESIDENTS. (NAME OF RESIDENT # 27) DID NOT TELL ME (NAME OF CNA # 1) (NAME OF CNA # 1) HURT HER ARM WHEN TRANSFERRING HER BUT SHE DID ACT A LITTLE SCARED--(?) (SIC)--(AND) TOLD (NAME OF CNA # 6 AND CNA # 7)" THIS HANDWRITTEN NURSING NOTE WAS SIGNED BY LPN # 5. REVIEW OF AN UNDATED, HANDWRITTEN NOTE BY LPN # 4 INDICATED, "IN REGARDS TO WED (Wednesday) OCT (October) 13TH WHEN I ENTERED (NAME OF RESIDENT # 17) ROOM (NAME OF CNA # 2) WAS STANDING WITH HER BACK TOWARD THE DOOR WITH THE PRIVACY CURTAIN PULLED BEHIND HER. THE SOILED LINEN WAS OFF THE BED AND (NAME OF RESIDENT # 17) WAS TURNED ON HER SIDE FACING THE WINDOW. (NAME OF CNA # 1) WAS HOLDER HER OVER SO I COULD INSERT A SUPPOSITORY. (NAME OF CNA # 1) DID SAY 'THIS WAS THE WORST ED CHECK I'VE EVER DONE.' I BELIEVE SEVERAL OTHER RES. HAD BEEN INCONT (INCONTINENT) BEFORE THEY CHECKED (NAME OF RESIDENT # 17). ... I DID NOT HEAR (NAME OF CNA # 1) SWEARING WHILE I WAS IN THE ROOM." THE HANDWRITTEN NOTE WAS SIGNED BY LPN # 4. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 6, CNA # 7, LPN # 8, OR THE DIETARY MANAGER WERE INTERVIEWED RELATED TO THE INCIDENT WHICH OCCURRED ON 10/13/10 AND THEIR REPORTED KNOWLEDGE OF PRIOR ALLEGED ABUSE BY CNA # 1. THERE WAS NO DOCUMENTATION TO INDICATE THE FACILITY STAFF WERE INSERVICED RELATED TO ABUSE AFTER THE INCIDENT ON 10/13/10. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 1 WAS REPORTED TO THE NURSE AIDE REGISTRY. THE STAFF DEVELOPMENT COORDINATOR PROVIDED DOCUMENTATION ON 10/28/10 TO INDICATE THE LAST ALL STAFF INSERVICE RELATED TO ABUSE AND NEGLECT WAS CONDUCTED ON 6/22/10. THE EMPLOYEE FILE FOR CNA # 1 WAS REVIEWED ON 10/28/10. CNA # 1 WAS HIRED ON 5/13/10. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "ONE-ON-ONE IN-SERVICE RECORD", DATED 6/11/10. THE TOPICS REVIEWED DURING THE INSERVICE INCLUDED RESIDENT RIGHTS, ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY, DEFINITIONS AND EXAMPLES OF ABUSE INDICATORS THAT ABUSE MAY HAVE OCCURRED, AND THE RAMIFICATIONS RELATED TO ALLEGED ABUSE SITUATIONS AND THE IMPACT ON CREDENTIALING AS A CNA. THE FORM INDICATED, "... PRESENTLY, AT THIS TIME YOU WILL BE DISQUALIFIED FROM THE CLINICAL CAREER LADDER FOR A PERIOD UP TO 12 MONTHS FROM YOUR LAST DAY WORK. ..." THE FORM WAS SIGNED BY CNA # 1 AND THE FACILITY STAFF DEVELOPMENT COORDINATOR. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "90-DAY PERFORMANCE APPRAISAL" FORM, WHICH WAS SIGNED BY THE EMPLOYEE ON 10/5/10. THE APPRAISAL INCLUDED THE FOLLOWING HANDWRITTEN STATEMENT: "IF A RES IS RESISTING CARE ASK THE NURSE TO HELP YOU WITH A PLAN (AND) COMMUNICATE MORE WITH NURSE AND OTHER CNA'S. DON'T HURRY RES THRU (THROUGH) THEIR CARE-ALLOW AMPLE TIME FOR COMMUNICATION...." REVIEW OF THE DAILY WORK SCHEDULE FOR 6/10 INDICATED CNA # 1 WORKED ON THE 2 WEST AND 1 WEST UNITS. THE 1 WEST UNIT IS ON THE FIRST FLOOR OF THE FACILITY AND THE 2 WEST UNIT WAS UPSTAIRS. THE EMPLOYEE FILE FOR CNA # 2 WAS REVIEWED ON 10/28/10 AT 3:10 P.M. THE DATE OF HIRE FOR CNA # 2 WAS 6/30/10. THERE WAS NO DOCUMENTATION IN THE FILE TO INDICATE CNA # 2 WAS PROVIDED TRAINING RELATED TO THE NEED TO INTERVENE IN AN ABUSIVE SITUATION AND REPORT ABUSE IMMEDIATELY. THERE WAS NO DOCUMENTATION TO INDICATE CNA # 2 WAS SUSPENDED OR REPRIMANDED RELATED TO HER FAILURE TO REPORT WITNESSED VERBAL AND PHYSICAL ABUSE IMMEDIATELY. DURING AN INTERVIEW WITH LPN # 5 (THE NURSE WHO RECORDED THE RESIDENT STATEMENTS ON 10/15/10) ON 10/28/10 AT 4:25 P.M., WITH UNIT MANAGER # 3 PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO THE UNIT MANAGER OR THE ON CALL NURSE. SHE INDICATED SHE WAS NOT SURE WHEN SHE WAS LAST TRAINED REGARDING THE FACILITY'S ABUSE POLICY. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE NOR WAS SHE AWARE OF ANY ABUSE IN THE FACILITY WITHIN THE LAST MONTH. SHE INDICATED YOU HAVE TO SEE ABUSE TO BE AWARE OF IT. SHE INDICATED SHE WAS GIVEN VERBAL CONCERNS ABOUT POSSIBLE ABUSE BUT YOU HAD TO GO BETWEEN GOSSIP AND WHAT THE RESIDENT SAYS. SHE INDICATED THE CONCERNS WERE DOCUMENTED AND THE NOTE SHOULD BE READ TO CLARIFY EXACTLY WHAT THE CONCERNS WERE. DURING AN INTERVIEW WITH CNA # 6, WITH UNIT MANAGER # 3, AS WITNESS ON 10/28/10 AT 4:25 P.M., CNA # 6 INDICATED TYPES OF ABUSE INCLUDED VERBAL, PHYSICAL, AND MISAPPROPRIATION OF PROPERTY. SHE INDICATED SHE WOULD REPORT ANY ABUSE TO HER UNIT MANAGER AND "IF THAT DIDN'T WORK I WOULD TELL THE DIRECTOR OF NURSING (DON), THE EXECUTIVE DIRECTOR (ED), ADULT PROTECTIVE SERVICES, AND THE DEPARTMENT OF HEALTH." SHE INDICATED SHE WOULD TRY TO TALK TO THE PERSON WHO WAS ABUSIVE, HELP THE RESIDENT AS MUCH AS POSSIBLE AND GET THE NURSE. SHE INDICATED SHE WAS INSERVICED REGULARLY ON ABUSE BUT COULD NOT REMEMBER WHEN THE LAST IN-SERVICE WAS. SHE INDICATED SHE HAD NOT OBSERVED OR REPORTED ANY ABUSE. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE HAVING OCCURRED IN THE BUILDING. SHE INDICATED SHE HAD NOT BEEN INTERVIEWED BY ANY STAFF RELATED TO ANY ALLEGATIONS OF STAFF ABUSE. SHE INDICATED SHE WAS COMFORTABLE REPORTING ABUSE. DURING AN INTERVIEW WITH CNA # 7 ON 10/28/10 AT 4:30 P.M., SHE INDICATED ONE TYPE OF ABUSE WAS VERBAL ABUSE WHICH INCLUDED TALKING NASTY OR HAVING OFFENSIVE LANGUAGE. SHE FURTHER INDICATED PHYSICAL ABUSE WAS A TYPE OF ABUSE AND INDICATED THIS WOULD INCLUDE YANKING A RESIDENT WHEN CHANGING THEIR CLOTHES, JERKING A RESIDENT'S ARMS, AND ROLLING A RESIDENT ROUGHLY WHEN USING A HOYER LIFT. CNA # 7, WHEN ASKED IF SHE HAD REPORTED ANY ABUSE, SHE INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, AND HER UNIT MANAGER, UNIT MANAGER # 3, OF AN INCIDENT OF SUSPECTED ABUSE MONTHS AGO INVOLVING CNA # 1. SHE FURTHER INDICATED SHE HAD WRITTEN A NOTE TO THE STAFF DEVELOPMENT COORDINATOR REGARDING CNA # 1'S treatment of [REDACTED]. CNA # 7, WHEN ASKED WHEN SHE HAD REPORTED, SHE SAID SHE HAD REPORTED THIS "A COUPLE OF MONTHS AGO," BUT CNA # 7 FOUND OUT LAST Sunday THAT CNA #1 WAS NO LONGER WORKING HERE." CNA # 7 INDICATED HAD REPORTED TO HER CHANGE NURSE AND HER UNIT MANAGER WHEN CNA #1 HAD HURT RESIDENT # 19'S ARM AND HAD OVERFED RESIDENT # 68. SHE FURTHER INDICATED THERE WERE A COUPLE OF OTHER RESIDENTS WHO DIDN'T LIKE CNA # 1. CNA # 7 INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, THE SAME DAY THE ABUSIVE CARE HAD HAPPENED. CNA # 7 INDICATED RESIDENT # 68 HAD BEEN FED FAST BY CNA #1. SHE SAID CNA # 1 HAD HELD HIS FOREHEAD BACK BY USING THE HEEL OF THE PALM OF HER HAND ON HIS FOREHEAD AND FORCING HIS HEAD BACK. CNA # 7 FURTHER INDICATED CNA #1 HAD LAUGHED AS SHE DID THIS, AS THE RESIDENT BECAME VERY UPSET. CNA # 7 INDICATED SHE HAD HEARD UNIT MANAGER # 3 TALKING WITH CNA # 1 AND HAD HEARD HER TELLING CNA # 1 SHE COULD NOT FEED RESIDENT # 68 IN THAT MANNER. SHE FURTHER INDICATED CNA # 10, CNA # 9, AND CNA # 6 HAD SEEN CNA # 1 LAUGHING AND FEEDING RESIDENT # 68 AT THE SAME TIME SHE HAD SEEN THIS HAPPENING. CNA # 7 INDICATED THIS HAD HAPPENED A COUPLE OF MONTHS AGO AND MORE THAN ONE TIME, SHE FURTHER INDICATED SHE HAD RARELY WORKED WITH HER SINCE THEN AS CNA # 1 WAS MOVED TO A DIFFERENT HALL. SHE INDICATED SHE WASN'T SURE IF THE FACILITY HAD DONE ANYTHING ABOUT CNA # 1 A COUPLE OF MONTHS AGO, BUT SHE WAS TOLD SHE COULDN'T WORK THIS MONTH ON THE 18TH, WHICH WAS A Monday. SHE WAS TOLD SHE COULD NOT COME BACK TO WORK LAST Sunday, October 24, 2010. DURING AN INTERVIEW WITH LPN # 8 ON 10/28/10 AT 4:45 P.M., WITH THE MINIMUM DATA SET ASSESSMENT (MDS) NURSE PRESENT, SHE INDICATED SHE WAS TRAINED ON ABUSE ABOUT A YEAR AGO. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE, AND SHE HAD NOT REPORTED ANY SUSPECTED ABUSE WITHIN THE LAST MONTH. DURING AN INTERVIEW WITH THE STAFF DEVELOPMENT COORDINATOR ON 10/28/10 AT 5:05 P.M., HE INDICATED HE DID NOT KNOW WHEN HE HAD DONE HIS LAST FACILITY WIDE ABUSE PREVENTION INSERVICE, BUT HE THOUGHT IT WAS IN THE FIRST QUARTER OF THIS YEAR. HE INDICATED HE HAD NOT WITNESSED ANY ABUSE OF ANY KIND IN THE FACILITY. HE INDICATED IF HE HAD SEEN OR HAD ANY ABUSE REPORTED TO HIM, HE WOULD REPORT IT TO HIS ADON (ASSISTANT DIRECTOR OF NURSES) IMMEDIATELY, AS SHE WAS HIS SUPERVISOR. HE INDICATED HE WAS TALKING WITH THE ADMINISTRATOR WHEN CNA # 2 HAD REPORTED SUSPECTED ABUSE TO THEM. CNA # 2 WAS REQUESTED TO WRITE A STATEMENT. HE INDICATED CNA # 2 HAD SAID CNA # 1 WAS THE PERSON WHO HAD WAS MAKING INAPPROPRIATE COMMENTS AND NEGATIVE STATEMENTS. HE INDICATED CNA # 2 HAD NOT REPORTED THIS THE DAY IT HAD HAPPENED, BUT HAD COME IN TO WORK EARLY THE NEXT DAY AND HAD THEN REPORTED WHAT HAD HAPPENED. CNA # 2 WAS REMOVED FROM THE SCHEDULE, BUT HE DID NOT REMEMBER THE DATE. HE INDICATED NO STAFF HAD WRITTEN HIM NOTES ABOUT ANY SUSPECTED ABUSE IN THE PAST FEW MONTHS. HE INDICATED HE "VAGUELY REMEMBERED ANOTHER INCIDENT IN THE PAST," BUT HE DID NOT KNOW WHAT CNA #1 HAD DONE. HE WAS ASKED AND HAD DONE A 1 TO 1 INSERVICE ABOUT RESIDENT RIGHTS AND THE ABUSE POLICIES WITH CNA # 1. HE INDICATED HE DID NOT HAVE ANY PAPERWORK ON THE 1 TO 1 INSERVICE, BUT THE ADMINISTRATOR WOULD HAVE IT IN HER FILES. HE INDICATED HE HAD NO OTHER STAFF MEMBERS WHO HAD TO BE REINSERVICED IN THE LAST COUPLE OF YEARS. IN FACT, HE COULD NOT REMEMBER DOING ANY OTHER 1 TO 1 INSERVICE WITH ANY STAFF MEMBER IN THE PAST 2 YEARS OR FOR AS LONG AS HE HAD WORKED IN THE FACILITY. DURING AN INTERVIEW WITH UNIT MANAGER # 3 ON 10/18/10 AT 5:10 P.M., WITH THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO HER IMMEDIATE SUPERVISOR, THE DIRECTOR OF NURSING, FIRST. SHE INDICATED SHE WAS NOT AWARE OF ANY REPORTED ABUSE, AND SHE HAD NOT SEEN ANY ABUSE. SHE INDICATED SHE HAD SPOKEN WITH CNA # 1 REGARDING HER RUSHING THROUGH CARE. SHE INDICATED SHE HAD REASSURED HER SHE DOESN'T HAVE TO RUSH THROUGH THINGS SO MUCH, AND THERE WERE OTHER STAFF TO HELP HER IF NEEDED. SHE INDICATED SHE WAS NOT SURE REGARDING THE DATES OF CNA # 1 RUSHING THROUGH CARE, BUT IT WAS DISCUSSED ON HER EVALUATION. SHE INDICATED AFTER TALKING, CNA # 1 APPEARED TO DO BETTER, BUT STARTED TO SPEED UP HER CARE AGAIN AFTER A WHILE. SHE INDICATED SHE KNEW CNA # 1 HAD FED RESIDENTS FAST, BUT SHE DIDN'T THINK IT WAS TOO SERIOUS. SHE INDICATED SHE FELT IT WAS BECAUSE CNA # 1 WAS YOUNG AND SHE NEEDED REASSURANCE AND THEN SHE COULD DO A BETTER JOB. UNIT MANAGER # 3 INDICATED RESIDENT # 68 WAS THE RESIDENT WHO WAS RUSHED DURING FEEDING. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE HERSELF. DURING AN INTERVIEW WITH THE DIETARY MANAGER ON 10/28/10 AT 5:10 P.M., SHE INDICATED CNA # 6 HAD SPOKEN TO HER RELATED TO CNA # 1, BUT COULD NOT REMEMBER WHAT THE SUBJECT WAS ABOUT. SHE INDICATED SHE TOLD CNA # 6 TO TALK TO THE DON OR THE ED. DURING AN INTERVIEW WITH CNA # 9 WITH THE ADON AS WITNESS ON 10/28/10 AT 5:35 P.M., SHE INDICATED CNA # 1 WAS ROUGH WITH RESIDENTS WHILE TAKING THEIR SHIRTS OFF. SHE INDICATED CNA # 1 GOT ROUGH TRYING TO RIP RESIDENT # 19'S SHIRT OFF DURING CARE. SHE INDICATED SHE TOLD CNA # 1 TO SLOW DOWN WHILE PROVIDING CARE. SHE INDICATED WHILE CNA # 1 WAS FEEDING RESIDENT # 68 SHE WOULD PUSH BACK HIS FOREHEAD AND FORCE FOOD INTO HIS MOUTH. SHE INDICATED RESIDENT # 68 WOULD GET AGITATED, FLAIL HIS HANDS, AND HAD KNOCKED OVER HIS FLUIDS. SHE INDICATED RESIDENT # 68 WOULD BE IN A GOOD MOOD AND THEN WOULD GET AGITATED WHEN CNA # 1 FED HIM. SHE INDICATED SHE HAD REPORTED THE ISSUES WITH THE CARE CNA # 1 PROVIDED MORE THAN THREE TIMES TO UNIT MANAGER # 3, LPN # 4, AND LPN # 5. SHE INDICATED SHE CONSIDERED THE CARE CNA # 1 PROVIDED TO THE RESIDENT'S TO BE ABUSIVE. DURING AN INTERVIEW WITH THE ADON ON 10/28/10 AT 5:45 P.M., SHE INDICATED CNA # 2 HAD COME IN to the facility on [DATE] AROUND 5:00 P.M., TO REPORT THAT CNA # 1 BEEN VERBALLY ABUSIVE TO THE RESIDENTS SHE CARED FOR ON THE LAST ROUND OF THE EVENING ON 10/13/10. SHE INDICATED SHE SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT HAPPENED. SHE INDICATED CNA # 2 HAD GONE HOME TO SLEEP BEFORE REPORTING THE INCIDENTS TO THE FACILITY. DURING AN INTERVIEW WITH THE ED, DON, AND THE CORPORATE CONSULTANT ON 10/28/10 AT 6:45 P.M., THE ED INDICATED CNA # 2 CAME INto the facility on [DATE] TO REPORT THE ALLEGATION OF ABUSE WHICH OCCURRED ON 10/13/10 INVOLVING CNA # 1. THE ED INDICATED SHE HAD CNA # 2 WRITE A STATEMENT. THE ED INDICATED CNA # 1 HAD BEEN IMMEDIATELY PULLED FROM THE FLOOR AND SENT HER HOME. THE TIME SHEET FOR CNA # 1 INDICATED SHE CLOCKED OUT OF THE 5:43 P.M. THE ED WOULD NOT COMMENT AS TO WHETHER CNA # 2 SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT OCCURRED. THE ED INDICATED SHE REPORTED THE ABUSE TO THE DEPARTMENT OF HEALTH THE NEXT DAY 10/15/10 AT 11:00 A.M. THE ED INDICATED AN ALL STAFF ABUSE IN-SERVICE HAD BEEN SCHEDULED FOR 10/26/10, BUT COULD NOT BE COMPLETED BECAUSE OF THE RECERTIFICATION SURVEY. SHE INDICATED IMMEDIATE VERBAL IN-SERVICES HAD BEEN COMPLETED WITH STAFF WHO WERE INVOLVED, BUT THESE HAD NOT BEEN DOCUMENTED. THE ED INDICATED CNA # 1 HAD BEEN TALKED TO BY UNIT MANAGER # 3 RELATED TO WORKING TOO FAST, ESPECIALLY IN THE DINING ROOM. SHE INDICATED THE RUSHING WITH CARE HAD BEEN IDENTIFIED AS A PERFORMANCE ISSUE. SHE INDICATED SHE WAS NOT AWARE OF ANY OTHER STAFF HAVING REPORTED ANY CONCERNS WITH THE CARE CNA # 1 HAD PROVIDED. SHE INDICATED SHE WAS UNAWARE OF WHAT PROMPTED THE INSERVICING RELATED TO RESIDENT RIGHTS AND ABUSE THAT CNA # 1 HAD RECEIVED IN June OF 2010. SHE INDICATED SHE HAD NOT SUSPENDED ANY STAFF RELATED TO NOT REPORTING CONCERNS WITH CNA # 1'S CARE. SHE INDICATED THE ALLEGATION OF ABUSE WAS THE FIRST THAT HAD BEEN REPORTED AND WRITTEN DOWN. SHE INDICATED NOTHING ELSE HAD BEEN REPORTED TO HER. 2. DURING AN INTERVIEW WITH RESIDENT # 19 ON 10/27/10 AT 8:15 A.M., SHE INDICATED STAFF TWIST AND YANK HER ARM. SHE WAS NOT ABLE TO IDENTIFY THE STAFF MEMBER AT THAT TIME. THE DIRECTOR OF NURSING WAS NOTIFIED OF THE CONCERNS EXPRESSED BY THE RESIDENT RELATED TO A STAFF MEMBER IMMEDIATELY FOLLOWING THE INTERVIEW WITH THE RESIDENT. AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 10/28/10 AT 10:25 A.M., INDICATED THE ABOVE ALLEGATION OF ABUSE WAS NOT REPORTED AT THAT TIME. SHE INDICATED SHE DID NOT TAKE IT AS AN ALLEGATION OF ABUSE. SHE INDICATED WHEN SHE SPOKE WITH RESIDENT # 19, THE RESIDENT DID NOT INDICATE A STAFF MEMBER WAS INVOLVED. SHE INDICATED SHE WAS CONDUCTING AN INVESTIGATION. THE INITIAL REPORT OF AN ALLEGATION OF ABUSE WAS NOT FAXED TO THE INDIANA STATE DEPARTMENT OF HEALTH UNTIL 11:43 A.M. ON 10/28/10. THE "RESIDENT EVENT INVESTIGATION QUESTIONNAIRE" REPORT WAS REVIEWED ON 10/28/10 AT 12:03 P.M. RESIDENT #19'S RECORD WAS REVIEWED ON 10/29/10 AT 9:35 A.M. RESIDENT #19'S [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET assessment dated [DATE] INDICATED RESIDENT #19 HAD SHORT-TERM MEMORY IMPAIRMENT, WAS MODERATELY IMPAIRED IN DECISION MAKING SKILLS WHICH REQUIRED CUES AND SUPERVISION, AND EXHIBITED INDICATORS OF REPETITIVE ANXIOUS COMPLAINTS/CONCERNS, AND CRYING AND TEARFULNESS UP TO FIVE DAYS A WEEK. THE ASSESSMENT INDICATED THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE OF ONE STAFF MEMBER FOR DRESSING AND PERSONAL HYGIENE. THE SOCIAL SERVICE NOTES INDICATED THE FOLLOWING: "...10/27/10 RES (RESIDENT) SHIRTS VERY DIFFICULT TO PUT ON. SS (SOCIAL SERVICE) TALKED C (WITH) HER ABOUT HAVING SHIRTS SPLIT UP BACK BY SEAMSTRESS TO MAKE IT EASIER TO GET ON. RES SELECTED 5 SHIRTS TO START WITH." "10/28/10 SS TALKED WITH RES ABOUT CONCERNS. SPEECH IMPOSSIBLE TO UNDERSTAND, VERY SOFT + (AND) SLURRED. WHEN ANSWERING YES/NO QUESTIONS UNABLE TO DISTINGUISH BETWEEN YES/NO ANSWERS. UNABLE TO NOD YES OR NO. STAFF WILL ANTICIPATE NEEDS." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. THE NURSES NOTES' INDICATED THE FOLLOWING: "...10/28/10 4:15 A (A.M.) 0 (NO) CONFUSION THIS SHIFT...." "10/28/10 8 A ...RES WAS UNABLE TO COMMUNICATE VERBALLY CLEARLY RES STOPPED ET (AND) STARTED SEV (SEVERAL) X'S (TIMES) AND SEEMED TO FORGET WHAT SHE WAS TRYING TO SAY...VERY SOFT ET UNABLE TO HEAR HER WORDS...ST (SPEECH THERAPY) NOTIFIED RES WAS HAVING DIFFICULTY C WORDS AND MAKING NEEDS KNOWN...." "...10/28/10 10 PM...RESIDENT ABLE TO ANSWER QUESTIONS APPROPRIATELY...." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. DOCUMENTATION WAS LACKING TO INDICATE THE RESIDENT HAD BEEN ASSESSED RELATED TO THE ALLEGATION OF ABUSE. DURING AN INTERVIEW WITH THE ED AND THE DON ON 10/28/10 AT 11:20 A.M., THE DON INDICATED RESIDENT #19 DID NOT REPORT ANY ALLEGATION OF ABUSE TO HER. THE DON INDICATED RESIDENT #19'S SPEECH WAS TOO GARBLED AND THE RESIDENT COULD NOT PROVIDE COMPLETE THOUGHTS OR SENTENCES. 3. REVIEW OF THE FACILITY "ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY AND PROCEDURE", ON 10/25/10 AT 6:00 P.M., DATED 2010, PROVIDED BY THE ADMINISTRATOR ON 10/25/10, INDICATED, "...VERBAL ABUSE-DEFINED AS THE USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING AND DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES, OR WITHIN HEARING DISTANCE, REGARDLESS OF THEIR AGE, ABILITY TO COMPREHEND, OR DISABILITY. EXAMPLES WOULD INCLUDE, BUT ARE NOT LIMITED TO, THREATS OF HARM, SAYING THINGS TO FRIGHTEN A RESIDENT, SUCH AS TELLING A RESIDENT THAT HE/SHE WILL NEVER BE ABLE TO SEE HIS/HER FAMILY MEMBER AGAIN; OR SCOLDING AND/OR SPEAKING TO THEM IN HARSH VOICE TONES. ... AMERICAN SENIOR COMMUNITIES WILL NOT PERMIT RESIDENTS TO BE SUBJECTED TO ABUSE BY ANYONE, INCLUDING EMPLOYEES, OTHER RESIDENTS, CONSULTANTS, VOLUNTEERS, STAFF OR PERSONNEL OF OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS, LEGAL GUARDIANS, SPONSORS, FRIENDS, OR OTHER INDIVIDUALS. ... EMPLOYEES WHETHER DIRECTOR CARE, CONTRACT STAFF, ANCILLARY DEPARTMENTS, VOLUNTEERS, OR CONSULTANTS RECEIVE INSTRUCTION/TRAINING ON ABUSE DURING ORIENTATION AND PERIODICALLY DURING ONGOING INSERVICE EDUCATION. THE TRAINING WILL INCLUDE: A. WHAT CONSTITUTES ABUSE B. TO WHOM TO REPORT ABUSE, AND WHEN C. HOW TO PROTECT RESIDENTS FROM IMMEDIATE DANGER D. INTERVENTION TECHNIQUES TO BE USED WITH RESIDENTS EXHIBITING AGGRESSIVE OR CATASTROPHIC REACTIONS E. HIS/HER RESPONSIBILITY UPON WITNESSING ABUSE F. HIS/HER ROLE IN AN INVESTIGATION.... ALL ABUSE ALLEGATIONS MUST BE REPORTED TO THE EXECUTIVE DIRECTOR IMMEDIATELY AND TO THE RESIDENT'S REPRESENTATIVE ... WITHIN 24 HOURS OF THE REPORT. FAILURE TO REPORT WILL RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING IMMEDIATE TERMINATION. THE EXECUTIVE DIRECTOR IS THE DESIGNATED INDIVIDUAL RESPONSIBLE FOR COORDINATING ALL EFFORTS IN THE INVESTIGATION OF ABUSE ALLEGATIONS, AND FOR ASSURING THAT ALL POLICIES AND PROCEDURES ARE FOLLOWED. IN THE ABSENCE OF THE EXECUTIVE DIRECTOR, THIS RESPONSIBILITY WILL BE DELEGATED TO THE DIRECTOR OF NURSING SERVICES.... IT IS THE RESPONSIBILITY OF EVERY EMPLOYEE OF AMERICAN SENIOR COMMUNITIES TO NOT ONLY REPORT ABUSE SITUATIONS, BUT ALSO SUSPICION OF ABUSE AND UNUSUAL OBSERVATIONS AND CIRCUMSTANCES TO HIS/HER IMMEDIATE SUPERVISOR....SUPERVISORY PERSONNEL ARE RESPONSIBLE TO MONITOR, THROUGH OBSERVATION AND COUNSELING AS NEEDED, STAFF/RESIDENT INTERACTIONS, AND THE PROVISION OF CARE AND SERVICES TO THE RESIDENT. STAFF MEMBERS SHOWING ANY TREND TOWARD IMPATIENCE OR FRUSTRATION IN ROUTINE DEALINGS WITH RESIDENTS SHOULD BE EVALUATED FOR POSSIBLE TEMPORARY REASSIGNMENT OF CARE OR UNPAID LEAVE OF ABSENCE.... IT IS THE POLICY OF AMERICAN SENIOR COMMUNITIES TO ASSURE APPROPRIATE INTERVENTIONS ARE IN PLACE AND FOLLOWED TO ASSURE SAFETY OF THE RESIDENT (S) IS MAINTAINED IS ABUSE IS IDENTIFIED (SIC) OR SUSPECTED. PROCEDURE: IF RESIDENT-TO-RESIDENT ABUSE IS IDENTIFIED, OR THERE IS SUSPICION OF RESIDENT-TO-RESIDENT ABUSE, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES RESIDENT-TO-RESIDENT ABUSE WILL IMMEDIATELY SEPARATE THE RESIDENTS INVOLVED. 2. THE INDIVIDUAL WHO WITNESSED THE ABUSE WILL REPORT THE SITUATION IMMEDIATELY TO HIS/HER SUPERVISOR. 4. THE STAFF MEMBER IN CHARGE WILL INITIATE THE INVESTIGATION IMMEDIATELY. 4. STAFF MEMBER (S) WILL MAINTAIN THE RESIDENT INITIATING THE ABUSE UNDER DIRECT SUPERVISION UNTIL THE INITIAL INVESTIGATION IS COMPLETE AND RESIDENT SAFETY IS MAINTAINED. 5. THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION. 6. THE CHARGE NURSE WILL ASSESS BOTH RESIDENTS INVOLVED TO DETERMINE IF PHYSICAL INJURIES HAVE OCCURRED a. RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT) ABOUT THE NATURE OF THE INCIDENT b. STATEMENTS WILL BE TAKEN FROM ANY ONE WITNESSING THE INCIDENT. 7. THE ATTENDING PHYSICIAN WILL BE NOTIFIED ... 8. THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED. 9. FOLLOW UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND RESIDENT (S) SAFETY IS MAINTAINED. 10. THE BEHAVIOR TEAM WILL ASSESS THE SITUATION AND MAKE RECOMMENDATIONS FOR FURTHER INTERVENTIONS.... IT IS THE RESPONSIBILITY OF THE ADMINISTRATOR/DIRECTOR OF NURSING TO REPORT THE ABUSE, OR ALLEGATIONS OF ABUSE, WITHIN 24 HOURS TO THE INDIANA STATE DEPARTMENT OF HEALTH....IF RESIDENT ABUSE IS IDENTIFIED OR SUSPECTED, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES THE ABUSE, OR HAS SUSPICION OF, SHALL IMMEDIATELY NOTIFY THE CHARGE NURSE OF THE UNIT, WHICH THE RESIDENT RESIDES.... THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION....THE RESIDENT (S) INVOLVED IN THE INCIDENT WILL BE ASSESSED FOR INJURIES....THE PHYSICIAN WILL BE NOTIFIED... THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED....AN INCIDENT REPORT WILL BE INITIATED... ALONG WITH A NARRATIVE DESCRIPTION IN THE NURSES' NOTES....RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT)ABOUT THE NATURE OF THE INCIDENT, AND THEIR STATEMENT WILL BE PUT IN WRITING....AN INVESTIGATION WILL BE DONE TO ASSURE OTHER RESIDENTS HAVE NOT BEEN AFFECTED BY THE INCIDENT OR INAPPROPRIATE BEHAVIOR, AND THE RESULTS DOCUMENTED....THE INVESTIGATION WILL INCLUDE: FACTS AND OBSERVATIONS BY INVOLVED EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING NON-EMPLOYEES/FACTS AND OBSERVATIONS FROM OTHERS WHO MIGHT HAVE PERTINENT INFORMATION/FACTS AND OBSERVATIONS BY THE SUPERVISOR OR INDIVIDUAL WHOM THE INITIAL REPORT WAS MADE...FOLLOW-UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED DURING EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND THE RESIDENT SAFETY IS MAINTAINED....THE EXECUTIVE DIRECTOR OR THE DIRECTOR OF NURSING IS RESPONSIBLE FOR NOTIFYING THE FOLLOWING AGENCIES, AS OUTLINED IN THE 'UNUSUAL OCCURENCE REPORTING GUIDELINES' INDIANA STATE DEPARTMENT OF HEALTH/ADULT PROTECTIVE SERVICES/OMBUDSMAN/DIRECTOR OF OPERATIONSZXXXZZ

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE RESIDENTS REMAINED FREE FROM ABUSE AS EVIDENCED BY THE FAILURE OF THE FACILITY TO IDENTIFY ABUSE, REPORT ABUSE, THOROUGHLY INVESTIGATE REPORTS OF ABUSE, EDUCATE STAFF ON THE FACILITY ABUSE PROTOCOL, IMPLEMENT THE FACILITY ABUSE POLICY, AND PUT SAFEGUARDS IN PLACE FOR RESIDENTS. THIS DEFICIENT PRACTICE DIRECTLY AFFECTED 4 RESIDENTS IN A SAMPLE OF 24 RESIDENTS AND 7 RESIDENTS IN A SUPPLEMENTAL SAMPLE OF 30 RESIDENTS. THIS DEFICIENT PRACTICE HAD THE POTENTIAL TO AFFECT 116 OF 116 RESIDENTS RESIDING IN THE CERTIFIED UNITS OF THE BUILDING. (RESIDENTS # 118, # 68, # 52, # 34, # 62, # 12, # 119, # 84, # 27, # 17, AND # 19) (CERTIFIED NURSING AIDES # 1, # 2, # 6, # 7, # 9, AND # 10) (LICENSED PRACTICAL NURSES # 4, # 5, AND # 8) (UNIT MANAGER # 3) (DIETARY MANAGER) (STAFF DEVELOPMENT COORDINATOR) THIS DEFICIENT PRACTICE RESULTED IN AN IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/29/10 AND BEGAN ON 10/13/10. THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/29/10. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/1/10, BUT THE FACILITY REMAINED OUT OF COMPLIANCE AT THE LEVEL OF AN ISOLATED INSTANCE OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM BECAUSE OF THE CONTINUED NEED FOR FOLLOW-UP RELATED TO ABUSE ALLEGATIONS, INSERVICING FOR NEW STAFF, AND ONGOING MONITORING OF ABUSE IN THE FACILITY. FINDINGS INCLUDE: 1. REVIEW OF A "FAX INCIDENT REPORTING FORM", ON 10/28/10 AT 12:30 A.M., INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS THE INITIAL REPORT OF THE INCIDENT. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "ON EVENING ROUNDS A CNA REPORTED THAT CNA # 1 WAS USING PROFANITY AND PROVIDING ROUGH CARE TO RESIDENTS." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." REVIEW OF A "FAX INCIDENT REPORTING FORM", INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS A 5 DAY FOLLOW-UP TO THE INCIDENT PREVIOUSLY REPORTED. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "REPORTED THAT (NAME OF CNA # 1) USED PROFANITY (AND) WAS ROUGH WHILE PROVIDING CARE TO RESIDENT." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION. ASSESSED RES (RESIDENTS) FOR INJURIES. NONE FOUND. SS (SOCIAL SERVICES) INTERVIEWED ALERT RESIDENTS ON THE UNIT. OTHER STAFF WERE INTERVIEWED." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER (NAME OF CNA # 1) HAS BEEN TERMINATED." REVIEW OF AN "ABUSE FLOW RECORD" FORM, INDICATED THE NATURE OF THE EVENT WAS ALLEGED VERBAL ABUSE. THE FORM INDICATED THE DATE OF THE EVENT WAS 10/13/10 FROM 9:00 P.M.-11:00 P.M., AND THE LOCATION OF THE EVENT WAS THE 1 WEST UNIT. THE EVENT WAS REPORTED TO THE ADMINISTRATOR/DESIGNEE ON 10/14/10 AT 5:25 P.M. THE EVENT WAS REPORTED BY CNA # 2. THE INDIVIDUAL SUSPENDED PENDING THE INVESTIGATION WAS CNA # 1, AND SHE WAS SUSPENDED ON 10/14/10. THE FORM INDICATED THE STAFF INTERVIEWED DURING THE INVESTIGATION PERIOD WERE RN # 3, LPN # 4, AND LPN # 5. THE FORM INDICATED RESIDENTS # 52, # 69, AND # 34 WERE INTERVIEWED DURING THE INVESTIGATION PERIOD. A NARRATIVE STATEMENT ON THE FORM INDICATED "STAFF REPORT EMPLOYEE GOES TO FAST (WITH) CARE. HAS BEEN COUNSELED TO SLOW DOWN. RES (RESIDENTS) WOULD NOT VERIFY ROUGH TREATMENT ON 10/15/10, BUT HAD STATED TO (INITIALS OF LPN # 5) BEFORE. EMPLOYEE LET GO D/T (DUE TO) CONTINUED POOR PERFORMANCE." THERE WERE NO SIGNATURES ON THE FORM TO INDICATE WHO COMPLETED THE "ABUSE FLOW RECORD" FORM. THERE WERE NO STAFF OR RESIDENT INTERVIEWS DOCUMENTED ON THE FORM, AND THERE WAS NO DOCUMENTATION TO INDICATE THE PHYSICIAN OR FAMILIES OF THE RESIDENTS INVOLVED WERE NOTIFIED. A HANDWRITTEN STATEMENT BY CNA # 2, DATED 10/14/10 AT 5:25 P.M., WAS THE INITIAL REPORT OF THE VERBAL AND PHYSICAL ABUSE WHICH OCCURED ON 10/13/10. THE STATEMENT INDICATED, "... DATED OF INCIDENT: 10/13/10 9 P (9:00 P.M.)-11 P (11:00 P.M.) DATE OF STATEMENT: 10/14/10 5:25 P.M. ... I WAS WORKING 1 WEST WITH (NAME OF CNA # 1) FIRST TIME WORKING 1 WEST AND FIRST TIME WORKING WITH HER. AT FIRST IT WAS GOING WELL SHE SHOWERED (NAME OF RESIDENT # 19) AND WAS REALLY NICE TO HER. WHEN IT CAME TO ROUNDS THE LAST ONE OF THE NIGHT WE STARTED ABOUT 10:00 P.M. THE FIRST FEW ROOMS (NAME OF CNA # 1) WAS CURSING SAYING 'F--- THIS S---' AND 'I HATE THIS (SIC) F---ING PEOPLE' I WAS SHOCKED BUT I MOVED ON TO THE NEXT RESIDENT BECAUSE I DIDN'T WANT TO FEED THE FIRE. WELL WE GOT TO (INITIAL) AND SHE WAS WET AND TAKING OFF HER GOWN. (NAME OF CNA # 1) WALKED IN TELLING HER TO 'KEEP HER F---ING CLOTHS (SIC) ON.' WHEN WE WERE CHANGING HER BED WE HAD TO DO A COMPLETE BED CHANGE (NAME OF CNA # 1) GATHERED THE LINEN WHILE I HELPED RESIDENT TAKE HER GOWN THE REST OF THE WAY OFF. (NAME OF CNA # 1) TOLD RESIDENT TO 'ROLL THE F--- OVER.' BUT THE RESIDENT COULDN'T DO TASK ON HER OWN SO (NAME OF CNA # 1) GOT MAD SAYING SHE 'HATED THIS FAT COW' CALLED HER A 'B----' MULTIPUL (SIC) OVER AND OVER SHOVING HER REALLY HARD I FELT SO BAD I TOLD (NAME OF CNA # 1) AFTER WE HAD THE BOTTOM SHEET ON i WOULD FINISH. SHE THREW THE BLANKETS ON HER BARELY COVRING (SIC) THE RESIDENT AND SAID THAT'S (SIC) GOOD I IGNORED THE STATEMENT AND FINISHED PUTTING ON RESIDENT CLEAN GOWN. (NAME OF CNA # 1) LEFT THE ROOM AND RESIDENT SAID SHE DIDN'T LIKE HER SHE WAS MEAN. RESIDENT WAS BARELY ABLE TO TALK BUT THAT'S (SIC) WHAT I GOT OUT OF WHAT SHE WAS SAYING. THEN AFTER THIS WE WENT ON WITH OUR ROUND AND WE GOT TO (NAME OF RESIDENT # 68) WHEN I WALKED IN ROOM (NAME OF CNA # 1) WAS RIPPING OFF THE BLANKETS WITH HER RIGHT ARM THROWING THEM ON THE FLOOR. LITERALLY RIPPED THEM FROM HIM. SHE SAID 'I HATE THIS MAN' RIGHT IN HIS FACE. THEN CHANGED HIS PADS SHOVING HIM FROM SIDE TO SIDE LIKE A RAG DOLE (SIC). HE BECAME COMBATIVE BY NOW TELLING HER TO LEAVE HIM ALONE. SHE SAID 'I WISH YOU WOULD JUST DIE.' AT THIS TIME SHE WAS TAKING THE BLANKETS AND DIRTY LAUNDRY OUT OF THE ROOM. I TRIED CALMING HIM DOWN AS I PUT HIS GOWN ON. I SAID "I'M SORRY AND SMILED AT HIM AND HE INSTANTLY CALMED DOWN, AND SMILED BACK. I COVERED HIM WITH A NEW SHEET AND BLANKET. AFTER THIS WE WENT INTO ANOTHER LADIES ROOM I CAN'T REMEMBER HER NAME, AND SHE HAD THROWN UP GREEN STUFF EVERYWHERE. (NAME OF CNA # 1) TURNED AND LOOKED OUT AT ME ASKING 'HOW THE NIGHT COULD GET ANY WORSE.' SHE CURSED SOME MORE I KINDA (SIC) STARTED IGNORING HER AT THIS POINT. BUT THIS IS THE ROOM THE NURSE (LPN # 4) CAME IN DURING (NAME OF CNA # 1) CURSING SHE DIDN'T SAY ANYTHING EXCEPT YOU SHOULD HAVE STARTED EARLIER. THEN LEFT. THIS WAS THE END OF THE BAD ATTITUDE AND VERBAL ABUSE THAT I WITNESSED." THE HANDWRITTEN STATEMENT WAS SIGNED BY CNA # 2. THE INVESTIGATION INTO THE INCIDENT ON 10/13/10 INCLUDED A HANDWRITTEN NURSING NOTE, WRITTEN BY LPN # 5. THE NOTE INDICATED "REFERENCE TO CNA: (NAME OF CNA # 1) RECEIVED COMPLAINTS FROM FOLLOWING RESIDENTS REGARDING RESIDENT CARE: 1. (NAME OF RESIDENT # 52); WHEN (NAME OF RESIDENT # 62) WAS ILL (AND) CONFUSED (RESIDENT NAME) STATED SHE TALKED MEAN TO HER (AND) WAS ROUGH (WITH) HER WHILE TRANSFERRING HER INTO BED. 2. (NAME OF RESIDENT # 34) COMPLAINED ABOUT WHEN CARING FOR (NAME OF RESIDENT # 12) (AND) (NAME OF RESIDENT # 119) THAT SHE WAS ROUGH DURING CARE. 3. (NAME OF RESIDENT # 84) COMPLAINT OF HER BE ROUGH (WITH) HER TO ANOTHER CNA (NAME OF CNA # 6) THAT SHE CAUSED HE (SIC) SKIN TEAR TO ARM BY PUSHING HER THROUGH THE DOOR. - (NAME OF RESIDENT # 84) REQUESTS SHE NOT CARE TO HER NEEDS IF POSSIBLE. 4. (NAME OF RESIDENT # 27) AFTER PUTTING HER TO BED 2 DIFFERENT TIMES (NAME OF RESIDENT # 27) WAS CRYING (AND) TOLD CNAS (NAME OF CNA # 6 AND NAME OF CNA # 7) SHE WAS ROUGH (WITH) HER. 5. (NAME OF RESIDENT # 27) TOLD ME SHE JERKS (NAME OF RESIDENT # 17) AROUND WHEN CARING FOR HER. 6. IN THE MAIN DR (DINING ROOM) SHE WAS FEEDING (NAME OF RESIDENT # 68)--(PER LPN # 8 AND CNA # 6) (NAME OF RESIDENT # 68) KEPT TELLING HER 'NO' WHEN SHE WAS FEEDING HIM (AND) SHE CONTINUED TO PUT FOOD IN HIS MOUTH (NAME OF LPN # 8) TOLD HER THAT WAS FORCE FEEDING. (NAME OF CNA # 1) STATED 'IT WASN'T' (NAME OF DIETARY MANAGER) ALSO WITNESSED THIS (AND) STATED TO (NAME OF LPN # 8) SHE WOULD REPORT INCIDENT IN AM MEETING. 7. (NAME OF RESIDENT # 19) COMPLAINED SHE WAS JERKING HER ARMS. ((NAME OF RESIDENT # 19) COMPLAINED TO ME) WHEN TRANSFER HER. WITNESSED BY (NAME OF CNA # 6). (NAME OF CNA # 1) DENIED. ANYTIME (NAME OF CNA # 1) HAS BEEN QUESTIONED ABOUT ROUGHNESS OR FORCE FEEDING SHE DENIES. I HAVE NOT WITNESSED ABUSE BY HER BUT RESIDENTS COMPLAIN (AND) REQUEST ANOTHER AIDE. HAVE TALKED TO (NAME OF CNA # 1) (AND) ASKED HER TO SLOW DOWN DURING CARE OF RESIDENTS (AND) TAKE HER TIME (AND) NOT RUSH.--(NAME OF CNA # 1) DENIES BEING ROUGH.--I BELIEVE THE RESIDENTS. (NAME OF RESIDENT # 27) DID NOT TELL ME (NAME OF CNA # 1) (NAME OF CNA # 1) HURT HER ARM WHEN TRANSFERRING HER BUT SHE DID ACT A LITTLE SCARED--(?) (SIC)--(AND) TOLD (NAME OF CNA # 6 AND CNA # 7)" THIS HANDWRITTEN NURSING NOTE WAS SIGNED BY LPN # 5. REVIEW OF AN UNDATED, HANDWRITTEN NOTE BY LPN # 4 INDICATED, "IN REGARDS TO WED (Wednesday) OCT (October) 13TH WHEN I ENTERED (NAME OF RESIDENT # 17) ROOM (NAME OF CNA # 2) WAS STANDING WITH HER BACK TOWARD THE DOOR WITH THE PRIVACY CURTAIN PULLED BEHIND HER. THE SOILED LINEN WAS OFF THE BED AND (NAME OF RESIDENT # 17) WAS TURNED ON HER SIDE FACING THE WINDOW. (NAME OF CNA # 1) WAS HOLDER HER OVER SO I COULD INSERT A SUPPOSITORY. (NAME OF CNA # 1) DID SAY 'THIS WAS THE WORST ED CHECK I'VE EVER DONE.' I BELIEVE SEVERAL OTHER RES. HAD BEEN INCONT (INCONTINENT) BEFORE THEY CHECKED (NAME OF RESIDENT # 17). ... I DID NOT HEAR (NAME OF CNA # 1) SWEARING WHILE I WAS IN THE ROOM." THE HANDWRITTEN NOTE WAS SIGNED BY LPN # 4. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 6, CNA # 7, LPN # 8, OR THE DIETARY MANAGER WERE INTERVIEWED RELATED TO THE INCIDENT WHICH OCCURRED ON 10/13/10 AND THEIR REPORTED KNOWLEDGE OF PRIOR ALLEGED ABUSE BY CNA # 1. THERE WAS NO DOCUMENTATION TO INDICATE THE FACILITY STAFF WERE INSERVICED RELATED TO ABUSE AFTER THE INCIDENT ON 10/13/10. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 1 WAS REPORTED TO THE NURSE AIDE REGISTRY. THE STAFF DEVELOPMENT COORDINATOR PROVIDED DOCUMENTATION ON 10/28/10 TO INDICATE THE LAST ALL STAFF INSERVICE RELATED TO ABUSE AND NEGLECT WAS CONDUCTED ON 6/22/10. THE EMPLOYEE FILE FOR CNA # 1 WAS REVIEWED ON 10/28/10. CNA # 1 WAS HIRED ON 5/13/10. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "ONE-ON-ONE IN-SERVICE RECORD", DATED 6/11/10. THE TOPICS REVIEWED DURING THE INSERVICE INCLUDED RESIDENT RIGHTS, ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY, DEFINITIONS AND EXAMPLES OF ABUSE INDICATORS THAT ABUSE MAY HAVE OCCURRED, AND THE RAMIFICATIONS RELATED TO ALLEGED ABUSE SITUATIONS AND THE IMPACT ON CREDENTIALING AS A CNA. THE FORM INDICATED, "... PRESENTLY, AT THIS TIME YOU WILL BE DISQUALIFIED FROM THE CLINICAL CAREER LADDER FOR A PERIOD UP TO 12 MONTHS FROM YOUR LAST DAY WORK. ..." THE FORM WAS SIGNED BY CNA # 1 AND THE FACILITY STAFF DEVELOPMENT COORDINATOR. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "90-DAY PERFORMANCE APPRAISAL" FORM, WHICH WAS SIGNED BY THE EMPLOYEE ON 10/5/10. THE APPRAISAL INCLUDED THE FOLLOWING HANDWRITTEN STATEMENT: "IF A RES IS RESISTING CARE ASK THE NURSE TO HELP YOU WITH A PLAN (AND) COMMUNICATE MORE WITH NURSE AND OTHER CNA'S. DON'T HURRY RES THRU (THROUGH) THEIR CARE-ALLOW AMPLE TIME FOR COMMUNICATION...." REVIEW OF THE DAILY WORK SCHEDULE FOR 6/10 INDICATED CNA # 1 WORKED ON THE 2 WEST AND 1 WEST UNITS. THE 1 WEST UNIT IS ON THE FIRST FLOOR OF THE FACILITY AND THE 2 WEST UNIT WAS UPSTAIRS. THE EMPLOYEE FILE FOR CNA # 2 WAS REVIEWED ON 10/28/10 AT 3:10 P.M. THE DATE OF HIRE FOR CNA # 2 WAS 6/30/10. THERE WAS NO DOCUMENTATION IN THE FILE TO INDICATE CNA # 2 WAS PROVIDED TRAINING RELATED TO THE NEED TO INTERVENE IN AN ABUSIVE SITUATION AND REPORT ABUSE IMMEDIATELY. THERE WAS NO DOCUMENTATION TO INDICATE CNA # 2 WAS SUSPENDED OR REPRIMANDED RELATED TO HER FAILURE TO REPORT WITNESSED VERBAL AND PHYSICAL ABUSE IMMEDIATELY. DURING AN INTERVIEW WITH LPN # 5 (THE NURSE WHO RECORDED THE RESIDENT STATEMENTS ON 10/15/10) ON 10/28/10 AT 4:25 P.M., WITH UNIT MANAGER # 3 PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO THE UNIT MANAGER OR THE ON CALL NURSE. SHE INDICATED SHE WAS NOT SURE WHEN SHE WAS LAST TRAINED REGARDING THE FACILITY'S ABUSE POLICY. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE NOR WAS SHE AWARE OF ANY ABUSE IN THE FACILITY WITHIN THE LAST MONTH. SHE INDICATED YOU HAVE TO SEE ABUSE TO BE AWARE OF IT. SHE INDICATED SHE WAS GIVEN VERBAL CONCERNS ABOUT POSSIBLE ABUSE BUT YOU HAD TO GO BETWEEN GOSSIP AND WHAT THE RESIDENT SAYS. SHE INDICATED THE CONCERNS WERE DOCUMENTED AND THE NOTE SHOULD BE READ TO CLARIFY EXACTLY WHAT THE CONCERNS WERE. DURING AN INTERVIEW WITH CNA # 6, WITH UNIT MANAGER # 3, AS WITNESS ON 10/28/10 AT 4:25 P.M., CNA # 6 INDICATED TYPES OF ABUSE INCLUDED VERBAL, PHYSICAL, AND MISAPPROPRIATION OF PROPERTY. SHE INDICATED SHE WOULD REPORT ANY ABUSE TO HER UNIT MANAGER AND "IF THAT DIDN'T WORK I WOULD TELL THE DIRECTOR OF NURSING (DON), THE EXECUTIVE DIRECTOR (ED), ADULT PROTECTIVE SERVICES, AND THE DEPARTMENT OF HEALTH." SHE INDICATED SHE WOULD TRY TO TALK TO THE PERSON WHO WAS ABUSIVE, HELP THE RESIDENT AS MUCH AS POSSIBLE AND GET THE NURSE. SHE INDICATED SHE WAS INSERVICED REGULARLY ON ABUSE BUT COULD NOT REMEMBER WHEN THE LAST IN-SERVICE WAS. SHE INDICATED SHE HAD NOT OBSERVED OR REPORTED ANY ABUSE. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE HAVING OCCURRED IN THE BUILDING. SHE INDICATED SHE HAD NOT BEEN INTERVIEWED BY ANY STAFF RELATED TO ANY ALLEGATIONS OF STAFF ABUSE. SHE INDICATED SHE WAS COMFORTABLE REPORTING ABUSE. DURING AN INTERVIEW WITH CNA # 7 ON 10/28/10 AT 4:30 P.M., SHE INDICATED ONE TYPE OF ABUSE WAS VERBAL ABUSE WHICH INCLUDED TALKING NASTY OR HAVING OFFENSIVE LANGUAGE. SHE FURTHER INDICATED PHYSICAL ABUSE WAS A TYPE OF ABUSE AND INDICATED THIS WOULD INCLUDE YANKING A RESIDENT WHEN CHANGING THEIR CLOTHES, JERKING A RESIDENT'S ARMS, AND ROLLING A RESIDENT ROUGHLY WHEN USING A HOYER LIFT. CNA # 7, WHEN ASKED IF SHE HAD REPORTED ANY ABUSE, SHE INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, AND HER UNIT MANAGER, UNIT MANAGER # 3, OF AN INCIDENT OF SUSPECTED ABUSE MONTHS AGO INVOLVING CNA # 1. SHE FURTHER INDICATED SHE HAD WRITTEN A NOTE TO THE STAFF DEVELOPMENT COORDINATOR REGARDING CNA # 1'S treatment of [REDACTED]. CNA # 7, WHEN ASKED WHEN SHE HAD REPORTED, SHE SAID SHE HAD REPORTED THIS "A COUPLE OF MONTHS AGO," BUT CNA # 7 FOUND OUT LAST Sunday THAT CNA #1 WAS NO LONGER WORKING HERE." CNA # 7 INDICATED HAD REPORTED TO HER CHANGE NURSE AND HER UNIT MANAGER WHEN CNA #1 HAD HURT RESIDENT # 19'S ARM AND HAD OVERFED RESIDENT # 68. SHE FURTHER INDICATED THERE WERE A COUPLE OF OTHER RESIDENTS WHO DIDN'T LIKE CNA # 1. CNA # 7 INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, THE SAME DAY THE ABUSIVE CARE HAD HAPPENED. CNA # 7 INDICATED RESIDENT # 68 HAD BEEN FED FAST BY CNA #1. SHE SAID CNA # 1 HAD HELD HIS FOREHEAD BACK BY USING THE HEEL OF THE PALM OF HER HAND ON HIS FOREHEAD AND FORCING HIS HEAD BACK. CNA # 7 FURTHER INDICATED CNA #1 HAD LAUGHED AS SHE DID THIS, AS THE RESIDENT BECAME VERY UPSET. CNA # 7 INDICATED SHE HAD HEARD UNIT MANAGER # 3 TALKING WITH CNA # 1 AND HAD HEARD HER TELLING CNA # 1 SHE COULD NOT FEED RESIDENT # 68 IN THAT MANNER. SHE FURTHER INDICATED CNA # 10, CNA # 9, AND CNA # 6 HAD SEEN CNA # 1 LAUGHING AND FEEDING RESIDENT # 68 AT THE SAME TIME SHE HAD SEEN THIS HAPPENING. CNA # 7 INDICATED THIS HAD HAPPENED A COUPLE OF MONTHS AGO AND MORE THAN ONE TIME, SHE FURTHER INDICATED SHE HAD RARELY WORKED WITH HER SINCE THEN AS CNA # 1 WAS MOVED TO A DIFFERENT HALL. SHE INDICATED SHE WASN'T SURE IF THE FACILITY HAD DONE ANYTHING ABOUT CNA # 1 A COUPLE OF MONTHS AGO, BUT SHE WAS TOLD SHE COULDN'T WORK THIS MONTH ON THE 18TH, WHICH WAS A Monday. SHE WAS TOLD SHE COULD NOT COME BACK TO WORK LAST Sunday, October 24, 2010. DURING AN INTERVIEW WITH LPN # 8 ON 10/28/10 AT 4:45 P.M., WITH THE MINIMUM DATA SET ASSESSMENT (MDS) NURSE PRESENT, SHE INDICATED SHE WAS TRAINED ON ABUSE ABOUT A YEAR AGO. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE, AND SHE HAD NOT REPORTED ANY SUSPECTED ABUSE WITHIN THE LAST MONTH. DURING AN INTERVIEW WITH THE STAFF DEVELOPMENT COORDINATOR ON 10/28/10 AT 5:05 P.M., HE INDICATED HE DID NOT KNOW WHEN HE HAD DONE HIS LAST FACILITY WIDE ABUSE PREVENTION INSERVICE, BUT HE THOUGHT IT WAS IN THE FIRST QUARTER OF THIS YEAR. HE INDICATED HE HAD NOT WITNESSED ANY ABUSE OF ANY KIND IN THE FACILITY. HE INDICATED IF HE HAD SEEN OR HAD ANY ABUSE REPORTED TO HIM, HE WOULD REPORT IT TO HIS ADON (ASSISTANT DIRECTOR OF NURSES) IMMEDIATELY, AS SHE WAS HIS SUPERVISOR. HE INDICATED HE WAS TALKING WITH THE ADMINISTRATOR WHEN CNA # 2 HAD REPORTED SUSPECTED ABUSE TO THEM. CNA # 2 WAS REQUESTED TO WRITE A STATEMENT. HE INDICATED CNA # 2 HAD SAID CNA # 1 WAS THE PERSON WHO HAD WAS MAKING INAPPROPRIATE COMMENTS AND NEGATIVE STATEMENTS. HE INDICATED CNA # 2 HAD NOT REPORTED THIS THE DAY IT HAD HAPPENED, BUT HAD COME IN TO WORK EARLY THE NEXT DAY AND HAD THEN REPORTED WHAT HAD HAPPENED. CNA # 2 WAS REMOVED FROM THE SCHEDULE, BUT HE DID NOT REMEMBER THE DATE. HE INDICATED NO STAFF HAD WRITTEN HIM NOTES ABOUT ANY SUSPECTED ABUSE IN THE PAST FEW MONTHS. HE INDICATED HE "VAGUELY REMEMBERED ANOTHER INCIDENT IN THE PAST," BUT HE DID NOT KNOW WHAT CNA #1 HAD DONE. HE WAS ASKED AND HAD DONE A 1 TO 1 INSERVICE ABOUT RESIDENT RIGHTS AND THE ABUSE POLICIES WITH CNA # 1. HE INDICATED HE DID NOT HAVE ANY PAPERWORK ON THE 1 TO 1 INSERVICE, BUT THE ADMINISTRATOR WOULD HAVE IT IN HER FILES. HE INDICATED HE HAD NO OTHER STAFF MEMBERS WHO HAD TO BE REINSERVICED IN THE LAST COUPLE OF YEARS. IN FACT, HE COULD NOT REMEMBER DOING ANY OTHER 1 TO 1 INSERVICE WITH ANY STAFF MEMBER IN THE PAST 2 YEARS OR FOR AS LONG AS HE HAD WORKED IN THE FACILITY. DURING AN INTERVIEW WITH UNIT MANAGER # 3 ON 10/18/10 AT 5:10 P.M., WITH THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO HER IMMEDIATE SUPERVISOR, THE DIRECTOR OF NURSING, FIRST. SHE INDICATED SHE WAS NOT AWARE OF ANY REPORTED ABUSE, AND SHE HAD NOT SEEN ANY ABUSE. SHE INDICATED SHE HAD SPOKEN WITH CNA # 1 REGARDING HER RUSHING THROUGH CARE. SHE INDICATED SHE HAD REASSURED HER SHE DOESN'T HAVE TO RUSH THROUGH THINGS SO MUCH, AND THERE WERE OTHER STAFF TO HELP HER IF NEEDED. SHE INDICATED SHE WAS NOT SURE REGARDING THE DATES OF CNA # 1 RUSHING THROUGH CARE, BUT IT WAS DISCUSSED ON HER EVALUATION. SHE INDICATED AFTER TALKING, CNA # 1 APPEARED TO DO BETTER, BUT STARTED TO SPEED UP HER CARE AGAIN AFTER A WHILE. SHE INDICATED SHE KNEW CNA # 1 HAD FED RESIDENTS FAST, BUT SHE DIDN'T THINK IT WAS TOO SERIOUS. SHE INDICATED SHE FELT IT WAS BECAUSE CNA # 1 WAS YOUNG AND SHE NEEDED REASSURANCE AND THEN SHE COULD DO A BETTER JOB. UNIT MANAGER # 3 INDICATED RESIDENT # 68 WAS THE RESIDENT WHO WAS RUSHED DURING FEEDING. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE HERSELF. DURING AN INTERVIEW WITH THE DIETARY MANAGER ON 10/28/10 AT 5:10 P.M., SHE INDICATED CNA # 6 HAD SPOKEN TO HER RELATED TO CNA # 1, BUT COULD NOT REMEMBER WHAT THE SUBJECT WAS ABOUT. SHE INDICATED SHE TOLD CNA # 6 TO TALK TO THE DON OR THE ED. DURING AN INTERVIEW WITH CNA # 9 WITH THE ADON AS WITNESS ON 10/28/10 AT 5:35 P.M., SHE INDICATED CNA # 1 WAS ROUGH WITH RESIDENTS WHILE TAKING THEIR SHIRTS OFF. SHE INDICATED CNA # 1 GOT ROUGH TRYING TO RIP RESIDENT # 19'S SHIRT OFF DURING CARE. SHE INDICATED SHE TOLD CNA # 1 TO SLOW DOWN WHILE PROVIDING CARE. SHE INDICATED WHILE CNA # 1 WAS FEEDING RESIDENT # 68 SHE WOULD PUSH BACK HIS FOREHEAD AND FORCE FOOD INTO HIS MOUTH. SHE INDICATED RESIDENT # 68 WOULD GET AGITATED, FLAIL HIS HANDS, AND HAD KNOCKED OVER HIS FLUIDS. SHE INDICATED RESIDENT # 68 WOULD BE IN A GOOD MOOD AND THEN WOULD GET AGITATED WHEN CNA # 1 FED HIM. SHE INDICATED SHE HAD REPORTED THE ISSUES WITH THE CARE CNA # 1 PROVIDED MORE THAN THREE TIMES TO UNIT MANAGER # 3, LPN # 4, AND LPN # 5. SHE INDICATED SHE CONSIDERED THE CARE CNA # 1 PROVIDED TO THE RESIDENT'S TO BE ABUSIVE. DURING AN INTERVIEW WITH THE ADON ON 10/28/10 AT 5:45 P.M., SHE INDICATED CNA # 2 HAD COME IN to the facility on [DATE] AROUND 5:00 P.M., TO REPORT THAT CNA # 1 BEEN VERBALLY ABUSIVE TO THE RESIDENTS SHE CARED FOR ON THE LAST ROUND OF THE EVENING ON 10/13/10. SHE INDICATED SHE SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT HAPPENED. SHE INDICATED CNA # 2 HAD GONE HOME TO SLEEP BEFORE REPORTING THE INCIDENTS TO THE FACILITY. DURING AN INTERVIEW WITH THE ED, DON, AND THE CORPORATE CONSULTANT ON 10/28/10 AT 6:45 P.M., THE ED INDICATED CNA # 2 CAME INto the facility on [DATE] TO REPORT THE ALLEGATION OF ABUSE WHICH OCCURRED ON 10/13/10 INVOLVING CNA # 1. THE ED INDICATED SHE HAD CNA # 2 WRITE A STATEMENT. THE ED INDICATED CNA # 1 HAD BEEN IMMEDIATELY PULLED FROM THE FLOOR AND SENT HER HOME. THE TIME SHEET FOR CNA # 1 INDICATED SHE CLOCKED OUT OF THE 5:43 P.M. THE ED WOULD NOT COMMENT AS TO WHETHER CNA # 2 SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT OCCURRED. THE ED INDICATED SHE REPORTED THE ABUSE TO THE DEPARTMENT OF HEALTH THE NEXT DAY 10/15/10 AT 11:00 A.M. THE ED INDICATED AN ALL STAFF ABUSE IN-SERVICE HAD BEEN SCHEDULED FOR 10/26/10, BUT COULD NOT BE COMPLETED BECAUSE OF THE RECERTIFICATION SURVEY. SHE INDICATED IMMEDIATE VERBAL IN-SERVICES HAD BEEN COMPLETED WITH STAFF WHO WERE INVOLVED, BUT THESE HAD NOT BEEN DOCUMENTED. THE ED INDICATED CNA # 1 HAD BEEN TALKED TO BY UNIT MANAGER # 3 RELATED TO WORKING TOO FAST, ESPECIALLY IN THE DINING ROOM. SHE INDICATED THE RUSHING WITH CARE HAD BEEN IDENTIFIED AS A PERFORMANCE ISSUE. SHE INDICATED SHE WAS NOT AWARE OF ANY OTHER STAFF HAVING REPORTED ANY CONCERNS WITH THE CARE CNA # 1 HAD PROVIDED. SHE INDICATED SHE WAS UNAWARE OF WHAT PROMPTED THE INSERVICING RELATED TO RESIDENT RIGHTS AND ABUSE THAT CNA # 1 HAD RECEIVED IN June OF 2010. SHE INDICATED SHE HAD NOT SUSPENDED ANY STAFF RELATED TO NOT REPORTING CONCERNS WITH CNA # 1'S CARE. SHE INDICATED THE ALLEGATION OF ABUSE WAS THE FIRST THAT HAD BEEN REPORTED AND WRITTEN DOWN. SHE INDICATED NOTHING ELSE HAD BEEN REPORTED TO HER. 2. DURING AN INTERVIEW WITH RESIDENT # 19 ON 10/27/10 AT 8:15 A.M., SHE INDICATED STAFF TWIST AND YANK HER ARM. SHE WAS NOT ABLE TO IDENTIFY THE STAFF MEMBER AT THAT TIME. THE DIRECTOR OF NURSING WAS NOTIFIED OF THE CONCERNS EXPRESSED BY THE RESIDENT RELATED TO A STAFF MEMBER IMMEDIATELY FOLLOWING THE INTERVIEW WITH THE RESIDENT. AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 10/28/10 AT 10:25 A.M., INDICATED THE ABOVE ALLEGATION OF ABUSE WAS NOT REPORTED AT THAT TIME. SHE INDICATED SHE DID NOT TAKE IT AS AN ALLEGATION OF ABUSE. SHE INDICATED WHEN SHE SPOKE WITH RESIDENT # 19, THE RESIDENT DID NOT INDICATE A STAFF MEMBER WAS INVOLVED. SHE INDICATED SHE WAS CONDUCTING AN INVESTIGATION. THE INITIAL REPORT OF AN ALLEGATION OF ABUSE WAS NOT FAXED TO THE INDIANA STATE DEPARTMENT OF HEALTH UNTIL 11:43 A.M. ON 10/28/10. THE "RESIDENT EVENT INVESTIGATION QUESTIONNAIRE" REPORT WAS REVIEWED ON 10/28/10 AT 12:03 P.M. RESIDENT #19'S RECORD WAS REVIEWED ON 10/29/10 AT 9:35 A.M. RESIDENT #19'S [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET assessment dated [DATE] INDICATED RESIDENT #19 HAD SHORT-TERM MEMORY IMPAIRMENT, WAS MODERATELY IMPAIRED IN DECISION MAKING SKILLS WHICH REQUIRED CUES AND SUPERVISION, AND EXHIBITED INDICATORS OF REPETITIVE ANXIOUS COMPLAINTS/CONCERNS, AND CRYING AND TEARFULNESS UP TO FIVE DAYS A WEEK. THE ASSESSMENT INDICATED THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE OF ONE STAFF MEMBER FOR DRESSING AND PERSONAL HYGIENE. THE SOCIAL SERVICE NOTES INDICATED THE FOLLOWING: "...10/27/10 RES (RESIDENT) SHIRTS VERY DIFFICULT TO PUT ON. SS (SOCIAL SERVICE) TALKED C (WITH) HER ABOUT HAVING SHIRTS SPLIT UP BACK BY SEAMSTRESS TO MAKE IT EASIER TO GET ON. RES SELECTED 5 SHIRTS TO START WITH." "10/28/10 SS TALKED WITH RES ABOUT CONCERNS. SPEECH IMPOSSIBLE TO UNDERSTAND, VERY SOFT + (AND) SLURRED. WHEN ANSWERING YES/NO QUESTIONS UNABLE TO DISTINGUISH BETWEEN YES/NO ANSWERS. UNABLE TO NOD YES OR NO. STAFF WILL ANTICIPATE NEEDS." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. THE NURSES NOTES' INDICATED THE FOLLOWING: "...10/28/10 4:15 A (A.M.) 0 (NO) CONFUSION THIS SHIFT...." "10/28/10 8 A ...RES WAS UNABLE TO COMMUNICATE VERBALLY CLEARLY RES STOPPED ET (AND) STARTED SEV (SEVERAL) X'S (TIMES) AND SEEMED TO FORGET WHAT SHE WAS TRYING TO SAY...VERY SOFT ET UNABLE TO HEAR HER WORDS...ST (SPEECH THERAPY) NOTIFIED RES WAS HAVING DIFFICULTY C WORDS AND MAKING NEEDS KNOWN...." "...10/28/10 10 PM...RESIDENT ABLE TO ANSWER QUESTIONS APPROPRIATELY...." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. DOCUMENTATION WAS LACKING TO INDICATE THE RESIDENT HAD BEEN ASSESSED RELATED TO THE ALLEGATION OF ABUSE. DURING AN INTERVIEW WITH THE ED AND THE DON ON 10/28/10 AT 11:20 A.M., THE DON INDICATED RESIDENT #19 DID NOT REPORT ANY ALLEGATION OF ABUSE TO HER. THE DON INDICATED RESIDENT #19'S SPEECH WAS TOO GARBLED AND THE RESIDENT COULD NOT PROVIDE COMPLETE THOUGHTS OR SENTENCES. 3. REVIEW OF THE FACILITY "ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY AND PROCEDURE", ON 10/25/10 AT 6:00 P.M., DATED 2010, PROVIDED BY THE ADMINISTRATOR ON 10/25/10, INDICATED, "...VERBAL ABUSE-DEFINED AS THE USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING AND DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES, OR WITHIN HEARING DISTANCE, REGARDLESS OF THEIR AGE, ABILITY TO COMPREHEND, OR DISABILITY. EXAMPLES WOULD INCLUDE, BUT ARE NOT LIMITED TO, THREATS OF HARM, SAYING THINGS TO FRIGHTEN A RESIDENT, SUCH AS TELLING A RESIDENT THAT HE/SHE WILL NEVER BE ABLE TO SEE HIS/HER FAMILY MEMBER AGAIN; OR SCOLDING AND/OR SPEAKING TO THEM IN HARSH VOICE TONES. ... AMERICAN SENIOR COMMUNITIES WILL NOT PERMIT RESIDENTS TO BE SUBJECTED TO ABUSE BY ANYONE, INCLUDING EMPLOYEES, OTHER RESIDENTS, CONSULTANTS, VOLUNTEERS, STAFF OR PERSONNEL OF OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS, LEGAL GUARDIANS, SPONSORS, FRIENDS, OR OTHER INDIVIDUALS. ... EMPLOYEES WHETHER DIRECTOR CARE, CONTRACT STAFF, ANCILLARY DEPARTMENTS, VOLUNTEERS, OR CONSULTANTS RECEIVE INSTRUCTION/TRAINING ON ABUSE DURING ORIENTATION AND PERIODICALLY DURING ONGOING INSERVICE EDUCATION. THE TRAINING WILL INCLUDE: A. WHAT CONSTITUTES ABUSE B. TO WHOM TO REPORT ABUSE, AND WHEN C. HOW TO PROTECT RESIDENTS FROM IMMEDIATE DANGER D. INTERVENTION TECHNIQUES TO BE USED WITH RESIDENTS EXHIBITING AGGRESSIVE OR CATASTROPHIC REACTIONS E. HIS/HER RESPONSIBILITY UPON WITNESSING ABUSE F. HIS/HER ROLE IN AN INVESTIGATION.... ALL ABUSE ALLEGATIONS MUST BE REPORTED TO THE EXECUTIVE DIRECTOR IMMEDIATELY AND TO THE RESIDENT'S REPRESENTATIVE ... WITHIN 24 HOURS OF THE REPORT. FAILURE TO REPORT WILL RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING IMMEDIATE TERMINATION. THE EXECUTIVE DIRECTOR IS THE DESIGNATED INDIVIDUAL RESPONSIBLE FOR COORDINATING ALL EFFORTS IN THE INVESTIGATION OF ABUSE ALLEGATIONS, AND FOR ASSURING THAT ALL POLICIES AND PROCEDURES ARE FOLLOWED. IN THE ABSENCE OF THE EXECUTIVE DIRECTOR, THIS RESPONSIBILITY WILL BE DELEGATED TO THE DIRECTOR OF NURSING SERVICES.... IT IS THE RESPONSIBILITY OF EVERY EMPLOYEE OF AMERICAN SENIOR COMMUNITIES TO NOT ONLY REPORT ABUSE SITUATIONS, BUT ALSO SUSPICION OF ABUSE AND UNUSUAL OBSERVATIONS AND CIRCUMSTANCES TO HIS/HER IMMEDIATE SUPERVISOR....SUPERVISORY PERSONNEL ARE RESPONSIBLE TO MONITOR, THROUGH OBSERVATION AND COUNSELING AS NEEDED, STAFF/RESIDENT INTERACTIONS, AND THE PROVISION OF CARE AND SERVICES TO THE RESIDENT. STAFF MEMBERS SHOWING ANY TREND TOWARD IMPATIENCE OR FRUSTRATION IN ROUTINE DEALINGS WITH RESIDENTS SHOULD BE EVALUATED FOR POSSIBLE TEMPORARY REASSIGNMENT OF CARE OR UNPAID LEAVE OF ABSENCE.... IT IS THE POLICY OF AMERICAN SENIOR COMMUNITIES TO ASSURE APPROPRIATE INTERVENTIONS ARE IN PLACE AND FOLLOWED TO ASSURE SAFETY OF THE RESIDENT (S) IS MAINTAINED IS ABUSE IS IDENTIFIED (SIC) OR SUSPECTED. PROCEDURE: IF RESIDENT-TO-RESIDENT ABUSE IS IDENTIFIED, OR THERE IS SUSPICION OF RESIDENT-TO-RESIDENT ABUSE, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES RESIDENT-TO-RESIDENT ABUSE WILL IMMEDIATELY SEPARATE THE RESIDENTS INVOLVED. 2. THE INDIVIDUAL WHO WITNESSED THE ABUSE WILL REPORT THE SITUATION IMMEDIATELY TO HIS/HER SUPERVISOR. 4. THE STAFF MEMBER IN CHARGE WILL INITIATE THE INVESTIGATION IMMEDIATELY. 4. STAFF MEMBER (S) WILL MAINTAIN THE RESIDENT INITIATING THE ABUSE UNDER DIRECT SUPERVISION UNTIL THE INITIAL INVESTIGATION IS COMPLETE AND RESIDENT SAFETY IS MAINTAINED. 5. THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION. 6. THE CHARGE NURSE WILL ASSESS BOTH RESIDENTS INVOLVED TO DETERMINE IF PHYSICAL INJURIES HAVE OCCURRED a. RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT) ABOUT THE NATURE OF THE INCIDENT b. STATEMENTS WILL BE TAKEN FROM ANY ONE WITNESSING THE INCIDENT. 7. THE ATTENDING PHYSICIAN WILL BE NOTIFIED ... 8. THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED. 9. FOLLOW UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND RESIDENT (S) SAFETY IS MAINTAINED. 10. THE BEHAVIOR TEAM WILL ASSESS THE SITUATION AND MAKE RECOMMENDATIONS FOR FURTHER INTERVENTIONS.... IT IS THE RESPONSIBILITY OF THE ADMINISTRATOR/DIRECTOR OF NURSING TO REPORT THE ABUSE, OR ALLEGATIONS OF ABUSE, WITHIN 24 HOURS TO THE INDIANA STATE DEPARTMENT OF HEALTH....IF RESIDENT ABUSE IS IDENTIFIED OR SUSPECTED, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES THE ABUSE, OR HAS SUSPICION OF, SHALL IMMEDIATELY NOTIFY THE CHARGE NURSE OF THE UNIT, WHICH THE RESIDENT RESIDES.... THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION....THE RESIDENT (S) INVOLVED IN THE INCIDENT WILL BE ASSESSED FOR INJURIES....THE PHYSICIAN WILL BE NOTIFIED... THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED....AN INCIDENT REPORT WILL BE INITIATED... ALONG WITH A NARRATIVE DESCRIPTION IN THE NURSES' NOTES....RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT)ABOUT THE NATURE OF THE INCIDENT, AND THEIR STATEMENT WILL BE PUT IN WRITING....AN INVESTIGATION WILL BE DONE TO ASSURE OTHER RESIDENTS HAVE NOT BEEN AFFECTED BY THE INCIDENT OR INAPPROPRIATE BEHAVIOR, AND THE RESULTS DOCUMENTED....THE INVESTIGATION WILL INCLUDE: FACTS AND OBSERVATIONS BY INVOLVED EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING NON-EMPLOYEES/FACTS AND OBSERVATIONS FROM OTHERS WHO MIGHT HAVE PERTINENT INFORMATION/FACTS AND OBSERVATIONS BY THE SUPERVISOR OR INDIVIDUAL WHOM THE INITIAL REPORT WAS MADE...FOLLOW-UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED DURING EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND THE RESIDENT SAFETY IS MAINTAINED....THE EXECUTIVE DIRECTOR OR THE DIRECTOR OF NURSING IS RESPONSIBLE FOR NOTIFYING THE FOLLOWING AGENCIES, AS OUTLINED IN THE 'UNUSUAL OCCURENCE REPORTING GUIDELINES' INDIANA STATE DEPARTMENT OF HEALTH/ADULT PROTECTIVE SERVICES/OMBUDSMAN/DIRECTOR OF OPERATIONSZXXXZZ

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE RESIDENTS REMAINED FREE FROM ABUSE AS EVIDENCED BY THE FAILURE OF THE FACILITY TO IDENTIFY ABUSE, REPORT ABUSE, THOROUGHLY INVESTIGATE REPORTS OF ABUSE, EDUCATE STAFF ON THE FACILITY ABUSE PROTOCOL, IMPLEMENT THE FACILITY ABUSE POLICY, AND PUT SAFEGUARDS IN PLACE FOR RESIDENTS. THIS DEFICIENT PRACTICE DIRECTLY AFFECTED 4 RESIDENTS IN A SAMPLE OF 24 RESIDENTS AND 7 RESIDENTS IN A SUPPLEMENTAL SAMPLE OF 30 RESIDENTS. THIS DEFICIENT PRACTICE HAD THE POTENTIAL TO AFFECT 116 OF 116 RESIDENTS RESIDING IN THE CERTIFIED UNITS OF THE BUILDING. (RESIDENTS # 118, # 68, # 52, # 34, # 62, # 12, # 119, # 84, # 27, # 17, AND # 19) (CERTIFIED NURSING AIDES # 1, # 2, # 6, # 7, # 9, AND # 10) (LICENSED PRACTICAL NURSES # 4, # 5, AND # 8) (UNIT MANAGER # 3) (DIETARY MANAGER) (STAFF DEVELOPMENT COORDINATOR) THIS DEFICIENT PRACTICE RESULTED IN AN IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/29/10 AND BEGAN ON 10/13/10. THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/29/10. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/1/10, BUT THE FACILITY REMAINED OUT OF COMPLIANCE AT THE LEVEL OF AN ISOLATED INSTANCE OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM BECAUSE OF THE CONTINUED NEED FOR FOLLOW-UP RELATED TO ABUSE ALLEGATIONS, INSERVICING FOR NEW STAFF, AND ONGOING MONITORING OF ABUSE IN THE FACILITY. FINDINGS INCLUDE: 1. REVIEW OF A "FAX INCIDENT REPORTING FORM", ON 10/28/10 AT 12:30 A.M., INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS THE INITIAL REPORT OF THE INCIDENT. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "ON EVENING ROUNDS A CNA REPORTED THAT CNA # 1 WAS USING PROFANITY AND PROVIDING ROUGH CARE TO RESIDENTS." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER SUSPENDED PENDING INVESTIGATION." REVIEW OF A "FAX INCIDENT REPORTING FORM", INDICATED AN INCIDENT OCCURRED IN THE FACILITY ON 10/13/10. THE FORM INDICATED IT WAS A 5 DAY FOLLOW-UP TO THE INCIDENT PREVIOUSLY REPORTED. THE FORM INDICATED RESIDENT # 118 AND RESIDENT # 68 WERE INVOLVED IN THE INCIDENT, AND CNA (CERTIFIED NURSING AIDE) # 1 AND CNA # 2 WERE INVOLVED IN THE INCIDENT. A BRIEF DESCRIPTION OF THE INCIDENT INDICATED, "REPORTED THAT (NAME OF CNA # 1) USED PROFANITY (AND) WAS ROUGH WHILE PROVIDING CARE TO RESIDENT." THE FORM INDICATED THE RESIDENTS WERE ASSESSED AND THERE WAS NO INJURY NOTED. THE IMMEDIATE ACTION/INTERVENTIONS INDICATED "STAFF MEMBER SUSPENDED PENDING INVESTIGATION. ASSESSED RES (RESIDENTS) FOR INJURIES. NONE FOUND. SS (SOCIAL SERVICES) INTERVIEWED ALERT RESIDENTS ON THE UNIT. OTHER STAFF WERE INTERVIEWED." PREVENTATIVE MEASURES TAKEN INDICATED, "STAFF MEMBER (NAME OF CNA # 1) HAS BEEN TERMINATED." REVIEW OF AN "ABUSE FLOW RECORD" FORM, INDICATED THE NATURE OF THE EVENT WAS ALLEGED VERBAL ABUSE. THE FORM INDICATED THE DATE OF THE EVENT WAS 10/13/10 FROM 9:00 P.M.-11:00 P.M., AND THE LOCATION OF THE EVENT WAS THE 1 WEST UNIT. THE EVENT WAS REPORTED TO THE ADMINISTRATOR/DESIGNEE ON 10/14/10 AT 5:25 P.M. THE EVENT WAS REPORTED BY CNA # 2. THE INDIVIDUAL SUSPENDED PENDING THE INVESTIGATION WAS CNA # 1, AND SHE WAS SUSPENDED ON 10/14/10. THE FORM INDICATED THE STAFF INTERVIEWED DURING THE INVESTIGATION PERIOD WERE RN # 3, LPN # 4, AND LPN # 5. THE FORM INDICATED RESIDENTS # 52, # 69, AND # 34 WERE INTERVIEWED DURING THE INVESTIGATION PERIOD. A NARRATIVE STATEMENT ON THE FORM INDICATED "STAFF REPORT EMPLOYEE GOES TO FAST (WITH) CARE. HAS BEEN COUNSELED TO SLOW DOWN. RES (RESIDENTS) WOULD NOT VERIFY ROUGH TREATMENT ON 10/15/10, BUT HAD STATED TO (INITIALS OF LPN # 5) BEFORE. EMPLOYEE LET GO D/T (DUE TO) CONTINUED POOR PERFORMANCE." THERE WERE NO SIGNATURES ON THE FORM TO INDICATE WHO COMPLETED THE "ABUSE FLOW RECORD" FORM. THERE WERE NO STAFF OR RESIDENT INTERVIEWS DOCUMENTED ON THE FORM, AND THERE WAS NO DOCUMENTATION TO INDICATE THE PHYSICIAN OR FAMILIES OF THE RESIDENTS INVOLVED WERE NOTIFIED. A HANDWRITTEN STATEMENT BY CNA # 2, DATED 10/14/10 AT 5:25 P.M., WAS THE INITIAL REPORT OF THE VERBAL AND PHYSICAL ABUSE WHICH OCCURED ON 10/13/10. THE STATEMENT INDICATED, "... DATED OF INCIDENT: 10/13/10 9 P (9:00 P.M.)-11 P (11:00 P.M.) DATE OF STATEMENT: 10/14/10 5:25 P.M. ... I WAS WORKING 1 WEST WITH (NAME OF CNA # 1) FIRST TIME WORKING 1 WEST AND FIRST TIME WORKING WITH HER. AT FIRST IT WAS GOING WELL SHE SHOWERED (NAME OF RESIDENT # 19) AND WAS REALLY NICE TO HER. WHEN IT CAME TO ROUNDS THE LAST ONE OF THE NIGHT WE STARTED ABOUT 10:00 P.M. THE FIRST FEW ROOMS (NAME OF CNA # 1) WAS CURSING SAYING 'F--- THIS S---' AND 'I HATE THIS (SIC) F---ING PEOPLE' I WAS SHOCKED BUT I MOVED ON TO THE NEXT RESIDENT BECAUSE I DIDN'T WANT TO FEED THE FIRE. WELL WE GOT TO (INITIAL) AND SHE WAS WET AND TAKING OFF HER GOWN. (NAME OF CNA # 1) WALKED IN TELLING HER TO 'KEEP HER F---ING CLOTHS (SIC) ON.' WHEN WE WERE CHANGING HER BED WE HAD TO DO A COMPLETE BED CHANGE (NAME OF CNA # 1) GATHERED THE LINEN WHILE I HELPED RESIDENT TAKE HER GOWN THE REST OF THE WAY OFF. (NAME OF CNA # 1) TOLD RESIDENT TO 'ROLL THE F--- OVER.' BUT THE RESIDENT COULDN'T DO TASK ON HER OWN SO (NAME OF CNA # 1) GOT MAD SAYING SHE 'HATED THIS FAT COW' CALLED HER A 'B----' MULTIPUL (SIC) OVER AND OVER SHOVING HER REALLY HARD I FELT SO BAD I TOLD (NAME OF CNA # 1) AFTER WE HAD THE BOTTOM SHEET ON i WOULD FINISH. SHE THREW THE BLANKETS ON HER BARELY COVRING (SIC) THE RESIDENT AND SAID THAT'S (SIC) GOOD I IGNORED THE STATEMENT AND FINISHED PUTTING ON RESIDENT CLEAN GOWN. (NAME OF CNA # 1) LEFT THE ROOM AND RESIDENT SAID SHE DIDN'T LIKE HER SHE WAS MEAN. RESIDENT WAS BARELY ABLE TO TALK BUT THAT'S (SIC) WHAT I GOT OUT OF WHAT SHE WAS SAYING. THEN AFTER THIS WE WENT ON WITH OUR ROUND AND WE GOT TO (NAME OF RESIDENT # 68) WHEN I WALKED IN ROOM (NAME OF CNA # 1) WAS RIPPING OFF THE BLANKETS WITH HER RIGHT ARM THROWING THEM ON THE FLOOR. LITERALLY RIPPED THEM FROM HIM. SHE SAID 'I HATE THIS MAN' RIGHT IN HIS FACE. THEN CHANGED HIS PADS SHOVING HIM FROM SIDE TO SIDE LIKE A RAG DOLE (SIC). HE BECAME COMBATIVE BY NOW TELLING HER TO LEAVE HIM ALONE. SHE SAID 'I WISH YOU WOULD JUST DIE.' AT THIS TIME SHE WAS TAKING THE BLANKETS AND DIRTY LAUNDRY OUT OF THE ROOM. I TRIED CALMING HIM DOWN AS I PUT HIS GOWN ON. I SAID "I'M SORRY AND SMILED AT HIM AND HE INSTANTLY CALMED DOWN, AND SMILED BACK. I COVERED HIM WITH A NEW SHEET AND BLANKET. AFTER THIS WE WENT INTO ANOTHER LADIES ROOM I CAN'T REMEMBER HER NAME, AND SHE HAD THROWN UP GREEN STUFF EVERYWHERE. (NAME OF CNA # 1) TURNED AND LOOKED OUT AT ME ASKING 'HOW THE NIGHT COULD GET ANY WORSE.' SHE CURSED SOME MORE I KINDA (SIC) STARTED IGNORING HER AT THIS POINT. BUT THIS IS THE ROOM THE NURSE (LPN # 4) CAME IN DURING (NAME OF CNA # 1) CURSING SHE DIDN'T SAY ANYTHING EXCEPT YOU SHOULD HAVE STARTED EARLIER. THEN LEFT. THIS WAS THE END OF THE BAD ATTITUDE AND VERBAL ABUSE THAT I WITNESSED." THE HANDWRITTEN STATEMENT WAS SIGNED BY CNA # 2. THE INVESTIGATION INTO THE INCIDENT ON 10/13/10 INCLUDED A HANDWRITTEN NURSING NOTE, WRITTEN BY LPN # 5. THE NOTE INDICATED "REFERENCE TO CNA: (NAME OF CNA # 1) RECEIVED COMPLAINTS FROM FOLLOWING RESIDENTS REGARDING RESIDENT CARE: 1. (NAME OF RESIDENT # 52); WHEN (NAME OF RESIDENT # 62) WAS ILL (AND) CONFUSED (RESIDENT NAME) STATED SHE TALKED MEAN TO HER (AND) WAS ROUGH (WITH) HER WHILE TRANSFERRING HER INTO BED. 2. (NAME OF RESIDENT # 34) COMPLAINED ABOUT WHEN CARING FOR (NAME OF RESIDENT # 12) (AND) (NAME OF RESIDENT # 119) THAT SHE WAS ROUGH DURING CARE. 3. (NAME OF RESIDENT # 84) COMPLAINT OF HER BE ROUGH (WITH) HER TO ANOTHER CNA (NAME OF CNA # 6) THAT SHE CAUSED HE (SIC) SKIN TEAR TO ARM BY PUSHING HER THROUGH THE DOOR. - (NAME OF RESIDENT # 84) REQUESTS SHE NOT CARE TO HER NEEDS IF POSSIBLE. 4. (NAME OF RESIDENT # 27) AFTER PUTTING HER TO BED 2 DIFFERENT TIMES (NAME OF RESIDENT # 27) WAS CRYING (AND) TOLD CNAS (NAME OF CNA # 6 AND NAME OF CNA # 7) SHE WAS ROUGH (WITH) HER. 5. (NAME OF RESIDENT # 27) TOLD ME SHE JERKS (NAME OF RESIDENT # 17) AROUND WHEN CARING FOR HER. 6. IN THE MAIN DR (DINING ROOM) SHE WAS FEEDING (NAME OF RESIDENT # 68)--(PER LPN # 8 AND CNA # 6) (NAME OF RESIDENT # 68) KEPT TELLING HER 'NO' WHEN SHE WAS FEEDING HIM (AND) SHE CONTINUED TO PUT FOOD IN HIS MOUTH (NAME OF LPN # 8) TOLD HER THAT WAS FORCE FEEDING. (NAME OF CNA # 1) STATED 'IT WASN'T' (NAME OF DIETARY MANAGER) ALSO WITNESSED THIS (AND) STATED TO (NAME OF LPN # 8) SHE WOULD REPORT INCIDENT IN AM MEETING. 7. (NAME OF RESIDENT # 19) COMPLAINED SHE WAS JERKING HER ARMS. ((NAME OF RESIDENT # 19) COMPLAINED TO ME) WHEN TRANSFER HER. WITNESSED BY (NAME OF CNA # 6). (NAME OF CNA # 1) DENIED. ANYTIME (NAME OF CNA # 1) HAS BEEN QUESTIONED ABOUT ROUGHNESS OR FORCE FEEDING SHE DENIES. I HAVE NOT WITNESSED ABUSE BY HER BUT RESIDENTS COMPLAIN (AND) REQUEST ANOTHER AIDE. HAVE TALKED TO (NAME OF CNA # 1) (AND) ASKED HER TO SLOW DOWN DURING CARE OF RESIDENTS (AND) TAKE HER TIME (AND) NOT RUSH.--(NAME OF CNA # 1) DENIES BEING ROUGH.--I BELIEVE THE RESIDENTS. (NAME OF RESIDENT # 27) DID NOT TELL ME (NAME OF CNA # 1) (NAME OF CNA # 1) HURT HER ARM WHEN TRANSFERRING HER BUT SHE DID ACT A LITTLE SCARED--(?) (SIC)--(AND) TOLD (NAME OF CNA # 6 AND CNA # 7)" THIS HANDWRITTEN NURSING NOTE WAS SIGNED BY LPN # 5. REVIEW OF AN UNDATED, HANDWRITTEN NOTE BY LPN # 4 INDICATED, "IN REGARDS TO WED (Wednesday) OCT (October) 13TH WHEN I ENTERED (NAME OF RESIDENT # 17) ROOM (NAME OF CNA # 2) WAS STANDING WITH HER BACK TOWARD THE DOOR WITH THE PRIVACY CURTAIN PULLED BEHIND HER. THE SOILED LINEN WAS OFF THE BED AND (NAME OF RESIDENT # 17) WAS TURNED ON HER SIDE FACING THE WINDOW. (NAME OF CNA # 1) WAS HOLDER HER OVER SO I COULD INSERT A SUPPOSITORY. (NAME OF CNA # 1) DID SAY 'THIS WAS THE WORST ED CHECK I'VE EVER DONE.' I BELIEVE SEVERAL OTHER RES. HAD BEEN INCONT (INCONTINENT) BEFORE THEY CHECKED (NAME OF RESIDENT # 17). ... I DID NOT HEAR (NAME OF CNA # 1) SWEARING WHILE I WAS IN THE ROOM." THE HANDWRITTEN NOTE WAS SIGNED BY LPN # 4. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 6, CNA # 7, LPN # 8, OR THE DIETARY MANAGER WERE INTERVIEWED RELATED TO THE INCIDENT WHICH OCCURRED ON 10/13/10 AND THEIR REPORTED KNOWLEDGE OF PRIOR ALLEGED ABUSE BY CNA # 1. THERE WAS NO DOCUMENTATION TO INDICATE THE FACILITY STAFF WERE INSERVICED RELATED TO ABUSE AFTER THE INCIDENT ON 10/13/10. THERE WAS NO DOCUMENTATION IN THE FACILITY INVESTIGATION TO INDICATE CNA # 1 WAS REPORTED TO THE NURSE AIDE REGISTRY. THE STAFF DEVELOPMENT COORDINATOR PROVIDED DOCUMENTATION ON 10/28/10 TO INDICATE THE LAST ALL STAFF INSERVICE RELATED TO ABUSE AND NEGLECT WAS CONDUCTED ON 6/22/10. THE EMPLOYEE FILE FOR CNA # 1 WAS REVIEWED ON 10/28/10. CNA # 1 WAS HIRED ON 5/13/10. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "ONE-ON-ONE IN-SERVICE RECORD", DATED 6/11/10. THE TOPICS REVIEWED DURING THE INSERVICE INCLUDED RESIDENT RIGHTS, ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY, DEFINITIONS AND EXAMPLES OF ABUSE INDICATORS THAT ABUSE MAY HAVE OCCURRED, AND THE RAMIFICATIONS RELATED TO ALLEGED ABUSE SITUATIONS AND THE IMPACT ON CREDENTIALING AS A CNA. THE FORM INDICATED, "... PRESENTLY, AT THIS TIME YOU WILL BE DISQUALIFIED FROM THE CLINICAL CAREER LADDER FOR A PERIOD UP TO 12 MONTHS FROM YOUR LAST DAY WORK. ..." THE FORM WAS SIGNED BY CNA # 1 AND THE FACILITY STAFF DEVELOPMENT COORDINATOR. THE EMPLOYEE FILE INDICATED CNA # 1 HAD A "90-DAY PERFORMANCE APPRAISAL" FORM, WHICH WAS SIGNED BY THE EMPLOYEE ON 10/5/10. THE APPRAISAL INCLUDED THE FOLLOWING HANDWRITTEN STATEMENT: "IF A RES IS RESISTING CARE ASK THE NURSE TO HELP YOU WITH A PLAN (AND) COMMUNICATE MORE WITH NURSE AND OTHER CNA'S. DON'T HURRY RES THRU (THROUGH) THEIR CARE-ALLOW AMPLE TIME FOR COMMUNICATION...." REVIEW OF THE DAILY WORK SCHEDULE FOR 6/10 INDICATED CNA # 1 WORKED ON THE 2 WEST AND 1 WEST UNITS. THE 1 WEST UNIT IS ON THE FIRST FLOOR OF THE FACILITY AND THE 2 WEST UNIT WAS UPSTAIRS. THE EMPLOYEE FILE FOR CNA # 2 WAS REVIEWED ON 10/28/10 AT 3:10 P.M. THE DATE OF HIRE FOR CNA # 2 WAS 6/30/10. THERE WAS NO DOCUMENTATION IN THE FILE TO INDICATE CNA # 2 WAS PROVIDED TRAINING RELATED TO THE NEED TO INTERVENE IN AN ABUSIVE SITUATION AND REPORT ABUSE IMMEDIATELY. THERE WAS NO DOCUMENTATION TO INDICATE CNA # 2 WAS SUSPENDED OR REPRIMANDED RELATED TO HER FAILURE TO REPORT WITNESSED VERBAL AND PHYSICAL ABUSE IMMEDIATELY. DURING AN INTERVIEW WITH LPN # 5 (THE NURSE WHO RECORDED THE RESIDENT STATEMENTS ON 10/15/10) ON 10/28/10 AT 4:25 P.M., WITH UNIT MANAGER # 3 PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO THE UNIT MANAGER OR THE ON CALL NURSE. SHE INDICATED SHE WAS NOT SURE WHEN SHE WAS LAST TRAINED REGARDING THE FACILITY'S ABUSE POLICY. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE NOR WAS SHE AWARE OF ANY ABUSE IN THE FACILITY WITHIN THE LAST MONTH. SHE INDICATED YOU HAVE TO SEE ABUSE TO BE AWARE OF IT. SHE INDICATED SHE WAS GIVEN VERBAL CONCERNS ABOUT POSSIBLE ABUSE BUT YOU HAD TO GO BETWEEN GOSSIP AND WHAT THE RESIDENT SAYS. SHE INDICATED THE CONCERNS WERE DOCUMENTED AND THE NOTE SHOULD BE READ TO CLARIFY EXACTLY WHAT THE CONCERNS WERE. DURING AN INTERVIEW WITH CNA # 6, WITH UNIT MANAGER # 3, AS WITNESS ON 10/28/10 AT 4:25 P.M., CNA # 6 INDICATED TYPES OF ABUSE INCLUDED VERBAL, PHYSICAL, AND MISAPPROPRIATION OF PROPERTY. SHE INDICATED SHE WOULD REPORT ANY ABUSE TO HER UNIT MANAGER AND "IF THAT DIDN'T WORK I WOULD TELL THE DIRECTOR OF NURSING (DON), THE EXECUTIVE DIRECTOR (ED), ADULT PROTECTIVE SERVICES, AND THE DEPARTMENT OF HEALTH." SHE INDICATED SHE WOULD TRY TO TALK TO THE PERSON WHO WAS ABUSIVE, HELP THE RESIDENT AS MUCH AS POSSIBLE AND GET THE NURSE. SHE INDICATED SHE WAS INSERVICED REGULARLY ON ABUSE BUT COULD NOT REMEMBER WHEN THE LAST IN-SERVICE WAS. SHE INDICATED SHE HAD NOT OBSERVED OR REPORTED ANY ABUSE. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE HAVING OCCURRED IN THE BUILDING. SHE INDICATED SHE HAD NOT BEEN INTERVIEWED BY ANY STAFF RELATED TO ANY ALLEGATIONS OF STAFF ABUSE. SHE INDICATED SHE WAS COMFORTABLE REPORTING ABUSE. DURING AN INTERVIEW WITH CNA # 7 ON 10/28/10 AT 4:30 P.M., SHE INDICATED ONE TYPE OF ABUSE WAS VERBAL ABUSE WHICH INCLUDED TALKING NASTY OR HAVING OFFENSIVE LANGUAGE. SHE FURTHER INDICATED PHYSICAL ABUSE WAS A TYPE OF ABUSE AND INDICATED THIS WOULD INCLUDE YANKING A RESIDENT WHEN CHANGING THEIR CLOTHES, JERKING A RESIDENT'S ARMS, AND ROLLING A RESIDENT ROUGHLY WHEN USING A HOYER LIFT. CNA # 7, WHEN ASKED IF SHE HAD REPORTED ANY ABUSE, SHE INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, AND HER UNIT MANAGER, UNIT MANAGER # 3, OF AN INCIDENT OF SUSPECTED ABUSE MONTHS AGO INVOLVING CNA # 1. SHE FURTHER INDICATED SHE HAD WRITTEN A NOTE TO THE STAFF DEVELOPMENT COORDINATOR REGARDING CNA # 1'S treatment of [REDACTED]. CNA # 7, WHEN ASKED WHEN SHE HAD REPORTED, SHE SAID SHE HAD REPORTED THIS "A COUPLE OF MONTHS AGO," BUT CNA # 7 FOUND OUT LAST Sunday THAT CNA #1 WAS NO LONGER WORKING HERE." CNA # 7 INDICATED HAD REPORTED TO HER CHANGE NURSE AND HER UNIT MANAGER WHEN CNA #1 HAD HURT RESIDENT # 19'S ARM AND HAD OVERFED RESIDENT # 68. SHE FURTHER INDICATED THERE WERE A COUPLE OF OTHER RESIDENTS WHO DIDN'T LIKE CNA # 1. CNA # 7 INDICATED SHE HAD TOLD HER CHARGE NURSE, LPN # 5, THE SAME DAY THE ABUSIVE CARE HAD HAPPENED. CNA # 7 INDICATED RESIDENT # 68 HAD BEEN FED FAST BY CNA #1. SHE SAID CNA # 1 HAD HELD HIS FOREHEAD BACK BY USING THE HEEL OF THE PALM OF HER HAND ON HIS FOREHEAD AND FORCING HIS HEAD BACK. CNA # 7 FURTHER INDICATED CNA #1 HAD LAUGHED AS SHE DID THIS, AS THE RESIDENT BECAME VERY UPSET. CNA # 7 INDICATED SHE HAD HEARD UNIT MANAGER # 3 TALKING WITH CNA # 1 AND HAD HEARD HER TELLING CNA # 1 SHE COULD NOT FEED RESIDENT # 68 IN THAT MANNER. SHE FURTHER INDICATED CNA # 10, CNA # 9, AND CNA # 6 HAD SEEN CNA # 1 LAUGHING AND FEEDING RESIDENT # 68 AT THE SAME TIME SHE HAD SEEN THIS HAPPENING. CNA # 7 INDICATED THIS HAD HAPPENED A COUPLE OF MONTHS AGO AND MORE THAN ONE TIME, SHE FURTHER INDICATED SHE HAD RARELY WORKED WITH HER SINCE THEN AS CNA # 1 WAS MOVED TO A DIFFERENT HALL. SHE INDICATED SHE WASN'T SURE IF THE FACILITY HAD DONE ANYTHING ABOUT CNA # 1 A COUPLE OF MONTHS AGO, BUT SHE WAS TOLD SHE COULDN'T WORK THIS MONTH ON THE 18TH, WHICH WAS A Monday. SHE WAS TOLD SHE COULD NOT COME BACK TO WORK LAST Sunday, October 24, 2010. DURING AN INTERVIEW WITH LPN # 8 ON 10/28/10 AT 4:45 P.M., WITH THE MINIMUM DATA SET ASSESSMENT (MDS) NURSE PRESENT, SHE INDICATED SHE WAS TRAINED ON ABUSE ABOUT A YEAR AGO. SHE INDICATED SHE WAS NOT AWARE OF ANY ABUSE, AND SHE HAD NOT REPORTED ANY SUSPECTED ABUSE WITHIN THE LAST MONTH. DURING AN INTERVIEW WITH THE STAFF DEVELOPMENT COORDINATOR ON 10/28/10 AT 5:05 P.M., HE INDICATED HE DID NOT KNOW WHEN HE HAD DONE HIS LAST FACILITY WIDE ABUSE PREVENTION INSERVICE, BUT HE THOUGHT IT WAS IN THE FIRST QUARTER OF THIS YEAR. HE INDICATED HE HAD NOT WITNESSED ANY ABUSE OF ANY KIND IN THE FACILITY. HE INDICATED IF HE HAD SEEN OR HAD ANY ABUSE REPORTED TO HIM, HE WOULD REPORT IT TO HIS ADON (ASSISTANT DIRECTOR OF NURSES) IMMEDIATELY, AS SHE WAS HIS SUPERVISOR. HE INDICATED HE WAS TALKING WITH THE ADMINISTRATOR WHEN CNA # 2 HAD REPORTED SUSPECTED ABUSE TO THEM. CNA # 2 WAS REQUESTED TO WRITE A STATEMENT. HE INDICATED CNA # 2 HAD SAID CNA # 1 WAS THE PERSON WHO HAD WAS MAKING INAPPROPRIATE COMMENTS AND NEGATIVE STATEMENTS. HE INDICATED CNA # 2 HAD NOT REPORTED THIS THE DAY IT HAD HAPPENED, BUT HAD COME IN TO WORK EARLY THE NEXT DAY AND HAD THEN REPORTED WHAT HAD HAPPENED. CNA # 2 WAS REMOVED FROM THE SCHEDULE, BUT HE DID NOT REMEMBER THE DATE. HE INDICATED NO STAFF HAD WRITTEN HIM NOTES ABOUT ANY SUSPECTED ABUSE IN THE PAST FEW MONTHS. HE INDICATED HE "VAGUELY REMEMBERED ANOTHER INCIDENT IN THE PAST," BUT HE DID NOT KNOW WHAT CNA #1 HAD DONE. HE WAS ASKED AND HAD DONE A 1 TO 1 INSERVICE ABOUT RESIDENT RIGHTS AND THE ABUSE POLICIES WITH CNA # 1. HE INDICATED HE DID NOT HAVE ANY PAPERWORK ON THE 1 TO 1 INSERVICE, BUT THE ADMINISTRATOR WOULD HAVE IT IN HER FILES. HE INDICATED HE HAD NO OTHER STAFF MEMBERS WHO HAD TO BE REINSERVICED IN THE LAST COUPLE OF YEARS. IN FACT, HE COULD NOT REMEMBER DOING ANY OTHER 1 TO 1 INSERVICE WITH ANY STAFF MEMBER IN THE PAST 2 YEARS OR FOR AS LONG AS HE HAD WORKED IN THE FACILITY. DURING AN INTERVIEW WITH UNIT MANAGER # 3 ON 10/18/10 AT 5:10 P.M., WITH THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING PRESENT, SHE INDICATED SHE WOULD REPORT ABUSE TO HER IMMEDIATE SUPERVISOR, THE DIRECTOR OF NURSING, FIRST. SHE INDICATED SHE WAS NOT AWARE OF ANY REPORTED ABUSE, AND SHE HAD NOT SEEN ANY ABUSE. SHE INDICATED SHE HAD SPOKEN WITH CNA # 1 REGARDING HER RUSHING THROUGH CARE. SHE INDICATED SHE HAD REASSURED HER SHE DOESN'T HAVE TO RUSH THROUGH THINGS SO MUCH, AND THERE WERE OTHER STAFF TO HELP HER IF NEEDED. SHE INDICATED SHE WAS NOT SURE REGARDING THE DATES OF CNA # 1 RUSHING THROUGH CARE, BUT IT WAS DISCUSSED ON HER EVALUATION. SHE INDICATED AFTER TALKING, CNA # 1 APPEARED TO DO BETTER, BUT STARTED TO SPEED UP HER CARE AGAIN AFTER A WHILE. SHE INDICATED SHE KNEW CNA # 1 HAD FED RESIDENTS FAST, BUT SHE DIDN'T THINK IT WAS TOO SERIOUS. SHE INDICATED SHE FELT IT WAS BECAUSE CNA # 1 WAS YOUNG AND SHE NEEDED REASSURANCE AND THEN SHE COULD DO A BETTER JOB. UNIT MANAGER # 3 INDICATED RESIDENT # 68 WAS THE RESIDENT WHO WAS RUSHED DURING FEEDING. SHE INDICATED SHE HAD NOT SEEN ANY ABUSE HERSELF. DURING AN INTERVIEW WITH THE DIETARY MANAGER ON 10/28/10 AT 5:10 P.M., SHE INDICATED CNA # 6 HAD SPOKEN TO HER RELATED TO CNA # 1, BUT COULD NOT REMEMBER WHAT THE SUBJECT WAS ABOUT. SHE INDICATED SHE TOLD CNA # 6 TO TALK TO THE DON OR THE ED. DURING AN INTERVIEW WITH CNA # 9 WITH THE ADON AS WITNESS ON 10/28/10 AT 5:35 P.M., SHE INDICATED CNA # 1 WAS ROUGH WITH RESIDENTS WHILE TAKING THEIR SHIRTS OFF. SHE INDICATED CNA # 1 GOT ROUGH TRYING TO RIP RESIDENT # 19'S SHIRT OFF DURING CARE. SHE INDICATED SHE TOLD CNA # 1 TO SLOW DOWN WHILE PROVIDING CARE. SHE INDICATED WHILE CNA # 1 WAS FEEDING RESIDENT # 68 SHE WOULD PUSH BACK HIS FOREHEAD AND FORCE FOOD INTO HIS MOUTH. SHE INDICATED RESIDENT # 68 WOULD GET AGITATED, FLAIL HIS HANDS, AND HAD KNOCKED OVER HIS FLUIDS. SHE INDICATED RESIDENT # 68 WOULD BE IN A GOOD MOOD AND THEN WOULD GET AGITATED WHEN CNA # 1 FED HIM. SHE INDICATED SHE HAD REPORTED THE ISSUES WITH THE CARE CNA # 1 PROVIDED MORE THAN THREE TIMES TO UNIT MANAGER # 3, LPN # 4, AND LPN # 5. SHE INDICATED SHE CONSIDERED THE CARE CNA # 1 PROVIDED TO THE RESIDENT'S TO BE ABUSIVE. DURING AN INTERVIEW WITH THE ADON ON 10/28/10 AT 5:45 P.M., SHE INDICATED CNA # 2 HAD COME IN to the facility on [DATE] AROUND 5:00 P.M., TO REPORT THAT CNA # 1 BEEN VERBALLY ABUSIVE TO THE RESIDENTS SHE CARED FOR ON THE LAST ROUND OF THE EVENING ON 10/13/10. SHE INDICATED SHE SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT HAPPENED. SHE INDICATED CNA # 2 HAD GONE HOME TO SLEEP BEFORE REPORTING THE INCIDENTS TO THE FACILITY. DURING AN INTERVIEW WITH THE ED, DON, AND THE CORPORATE CONSULTANT ON 10/28/10 AT 6:45 P.M., THE ED INDICATED CNA # 2 CAME INto the facility on [DATE] TO REPORT THE ALLEGATION OF ABUSE WHICH OCCURRED ON 10/13/10 INVOLVING CNA # 1. THE ED INDICATED SHE HAD CNA # 2 WRITE A STATEMENT. THE ED INDICATED CNA # 1 HAD BEEN IMMEDIATELY PULLED FROM THE FLOOR AND SENT HER HOME. THE TIME SHEET FOR CNA # 1 INDICATED SHE CLOCKED OUT OF THE 5:43 P.M. THE ED WOULD NOT COMMENT AS TO WHETHER CNA # 2 SHOULD HAVE REPORTED THE ABUSE IMMEDIATELY WHEN IT OCCURRED. THE ED INDICATED SHE REPORTED THE ABUSE TO THE DEPARTMENT OF HEALTH THE NEXT DAY 10/15/10 AT 11:00 A.M. THE ED INDICATED AN ALL STAFF ABUSE IN-SERVICE HAD BEEN SCHEDULED FOR 10/26/10, BUT COULD NOT BE COMPLETED BECAUSE OF THE RECERTIFICATION SURVEY. SHE INDICATED IMMEDIATE VERBAL IN-SERVICES HAD BEEN COMPLETED WITH STAFF WHO WERE INVOLVED, BUT THESE HAD NOT BEEN DOCUMENTED. THE ED INDICATED CNA # 1 HAD BEEN TALKED TO BY UNIT MANAGER # 3 RELATED TO WORKING TOO FAST, ESPECIALLY IN THE DINING ROOM. SHE INDICATED THE RUSHING WITH CARE HAD BEEN IDENTIFIED AS A PERFORMANCE ISSUE. SHE INDICATED SHE WAS NOT AWARE OF ANY OTHER STAFF HAVING REPORTED ANY CONCERNS WITH THE CARE CNA # 1 HAD PROVIDED. SHE INDICATED SHE WAS UNAWARE OF WHAT PROMPTED THE INSERVICING RELATED TO RESIDENT RIGHTS AND ABUSE THAT CNA # 1 HAD RECEIVED IN June OF 2010. SHE INDICATED SHE HAD NOT SUSPENDED ANY STAFF RELATED TO NOT REPORTING CONCERNS WITH CNA # 1'S CARE. SHE INDICATED THE ALLEGATION OF ABUSE WAS THE FIRST THAT HAD BEEN REPORTED AND WRITTEN DOWN. SHE INDICATED NOTHING ELSE HAD BEEN REPORTED TO HER. 2. DURING AN INTERVIEW WITH RESIDENT # 19 ON 10/27/10 AT 8:15 A.M., SHE INDICATED STAFF TWIST AND YANK HER ARM. SHE WAS NOT ABLE TO IDENTIFY THE STAFF MEMBER AT THAT TIME. THE DIRECTOR OF NURSING WAS NOTIFIED OF THE CONCERNS EXPRESSED BY THE RESIDENT RELATED TO A STAFF MEMBER IMMEDIATELY FOLLOWING THE INTERVIEW WITH THE RESIDENT. AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 10/28/10 AT 10:25 A.M., INDICATED THE ABOVE ALLEGATION OF ABUSE WAS NOT REPORTED AT THAT TIME. SHE INDICATED SHE DID NOT TAKE IT AS AN ALLEGATION OF ABUSE. SHE INDICATED WHEN SHE SPOKE WITH RESIDENT # 19, THE RESIDENT DID NOT INDICATE A STAFF MEMBER WAS INVOLVED. SHE INDICATED SHE WAS CONDUCTING AN INVESTIGATION. THE INITIAL REPORT OF AN ALLEGATION OF ABUSE WAS NOT FAXED TO THE INDIANA STATE DEPARTMENT OF HEALTH UNTIL 11:43 A.M. ON 10/28/10. THE "RESIDENT EVENT INVESTIGATION QUESTIONNAIRE" REPORT WAS REVIEWED ON 10/28/10 AT 12:03 P.M. RESIDENT #19'S RECORD WAS REVIEWED ON 10/29/10 AT 9:35 A.M. RESIDENT #19'S [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET assessment dated [DATE] INDICATED RESIDENT #19 HAD SHORT-TERM MEMORY IMPAIRMENT, WAS MODERATELY IMPAIRED IN DECISION MAKING SKILLS WHICH REQUIRED CUES AND SUPERVISION, AND EXHIBITED INDICATORS OF REPETITIVE ANXIOUS COMPLAINTS/CONCERNS, AND CRYING AND TEARFULNESS UP TO FIVE DAYS A WEEK. THE ASSESSMENT INDICATED THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE OF ONE STAFF MEMBER FOR DRESSING AND PERSONAL HYGIENE. THE SOCIAL SERVICE NOTES INDICATED THE FOLLOWING: "...10/27/10 RES (RESIDENT) SHIRTS VERY DIFFICULT TO PUT ON. SS (SOCIAL SERVICE) TALKED C (WITH) HER ABOUT HAVING SHIRTS SPLIT UP BACK BY SEAMSTRESS TO MAKE IT EASIER TO GET ON. RES SELECTED 5 SHIRTS TO START WITH." "10/28/10 SS TALKED WITH RES ABOUT CONCERNS. SPEECH IMPOSSIBLE TO UNDERSTAND, VERY SOFT + (AND) SLURRED. WHEN ANSWERING YES/NO QUESTIONS UNABLE TO DISTINGUISH BETWEEN YES/NO ANSWERS. UNABLE TO NOD YES OR NO. STAFF WILL ANTICIPATE NEEDS." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. THE NURSES NOTES' INDICATED THE FOLLOWING: "...10/28/10 4:15 A (A.M.) 0 (NO) CONFUSION THIS SHIFT...." "10/28/10 8 A ...RES WAS UNABLE TO COMMUNICATE VERBALLY CLEARLY RES STOPPED ET (AND) STARTED SEV (SEVERAL) X'S (TIMES) AND SEEMED TO FORGET WHAT SHE WAS TRYING TO SAY...VERY SOFT ET UNABLE TO HEAR HER WORDS...ST (SPEECH THERAPY) NOTIFIED RES WAS HAVING DIFFICULTY C WORDS AND MAKING NEEDS KNOWN...." "...10/28/10 10 PM...RESIDENT ABLE TO ANSWER QUESTIONS APPROPRIATELY...." DOCUMENTATION WAS LACKING TO INDICATE THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF THE RESIDENT HAVING BEEN NAMED IN AN ALLEGATION OF ABUSE. DOCUMENTATION WAS LACKING TO INDICATE THE RESIDENT HAD BEEN ASSESSED RELATED TO THE ALLEGATION OF ABUSE. DURING AN INTERVIEW WITH THE ED AND THE DON ON 10/28/10 AT 11:20 A.M., THE DON INDICATED RESIDENT #19 DID NOT REPORT ANY ALLEGATION OF ABUSE TO HER. THE DON INDICATED RESIDENT #19'S SPEECH WAS TOO GARBLED AND THE RESIDENT COULD NOT PROVIDE COMPLETE THOUGHTS OR SENTENCES. 3. REVIEW OF THE FACILITY "ABUSE PROHIBITION, REPORTING, AND INVESTIGATION POLICY AND PROCEDURE", ON 10/25/10 AT 6:00 P.M., DATED 2010, PROVIDED BY THE ADMINISTRATOR ON 10/25/10, INDICATED, "...VERBAL ABUSE-DEFINED AS THE USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING AND DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES, OR WITHIN HEARING DISTANCE, REGARDLESS OF THEIR AGE, ABILITY TO COMPREHEND, OR DISABILITY. EXAMPLES WOULD INCLUDE, BUT ARE NOT LIMITED TO, THREATS OF HARM, SAYING THINGS TO FRIGHTEN A RESIDENT, SUCH AS TELLING A RESIDENT THAT HE/SHE WILL NEVER BE ABLE TO SEE HIS/HER FAMILY MEMBER AGAIN; OR SCOLDING AND/OR SPEAKING TO THEM IN HARSH VOICE TONES. ... AMERICAN SENIOR COMMUNITIES WILL NOT PERMIT RESIDENTS TO BE SUBJECTED TO ABUSE BY ANYONE, INCLUDING EMPLOYEES, OTHER RESIDENTS, CONSULTANTS, VOLUNTEERS, STAFF OR PERSONNEL OF OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS, LEGAL GUARDIANS, SPONSORS, FRIENDS, OR OTHER INDIVIDUALS. ... EMPLOYEES WHETHER DIRECTOR CARE, CONTRACT STAFF, ANCILLARY DEPARTMENTS, VOLUNTEERS, OR CONSULTANTS RECEIVE INSTRUCTION/TRAINING ON ABUSE DURING ORIENTATION AND PERIODICALLY DURING ONGOING INSERVICE EDUCATION. THE TRAINING WILL INCLUDE: A. WHAT CONSTITUTES ABUSE B. TO WHOM TO REPORT ABUSE, AND WHEN C. HOW TO PROTECT RESIDENTS FROM IMMEDIATE DANGER D. INTERVENTION TECHNIQUES TO BE USED WITH RESIDENTS EXHIBITING AGGRESSIVE OR CATASTROPHIC REACTIONS E. HIS/HER RESPONSIBILITY UPON WITNESSING ABUSE F. HIS/HER ROLE IN AN INVESTIGATION.... ALL ABUSE ALLEGATIONS MUST BE REPORTED TO THE EXECUTIVE DIRECTOR IMMEDIATELY AND TO THE RESIDENT'S REPRESENTATIVE ... WITHIN 24 HOURS OF THE REPORT. FAILURE TO REPORT WILL RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING IMMEDIATE TERMINATION. THE EXECUTIVE DIRECTOR IS THE DESIGNATED INDIVIDUAL RESPONSIBLE FOR COORDINATING ALL EFFORTS IN THE INVESTIGATION OF ABUSE ALLEGATIONS, AND FOR ASSURING THAT ALL POLICIES AND PROCEDURES ARE FOLLOWED. IN THE ABSENCE OF THE EXECUTIVE DIRECTOR, THIS RESPONSIBILITY WILL BE DELEGATED TO THE DIRECTOR OF NURSING SERVICES.... IT IS THE RESPONSIBILITY OF EVERY EMPLOYEE OF AMERICAN SENIOR COMMUNITIES TO NOT ONLY REPORT ABUSE SITUATIONS, BUT ALSO SUSPICION OF ABUSE AND UNUSUAL OBSERVATIONS AND CIRCUMSTANCES TO HIS/HER IMMEDIATE SUPERVISOR....SUPERVISORY PERSONNEL ARE RESPONSIBLE TO MONITOR, THROUGH OBSERVATION AND COUNSELING AS NEEDED, STAFF/RESIDENT INTERACTIONS, AND THE PROVISION OF CARE AND SERVICES TO THE RESIDENT. STAFF MEMBERS SHOWING ANY TREND TOWARD IMPATIENCE OR FRUSTRATION IN ROUTINE DEALINGS WITH RESIDENTS SHOULD BE EVALUATED FOR POSSIBLE TEMPORARY REASSIGNMENT OF CARE OR UNPAID LEAVE OF ABSENCE.... IT IS THE POLICY OF AMERICAN SENIOR COMMUNITIES TO ASSURE APPROPRIATE INTERVENTIONS ARE IN PLACE AND FOLLOWED TO ASSURE SAFETY OF THE RESIDENT (S) IS MAINTAINED IS ABUSE IS IDENTIFIED (SIC) OR SUSPECTED. PROCEDURE: IF RESIDENT-TO-RESIDENT ABUSE IS IDENTIFIED, OR THERE IS SUSPICION OF RESIDENT-TO-RESIDENT ABUSE, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES RESIDENT-TO-RESIDENT ABUSE WILL IMMEDIATELY SEPARATE THE RESIDENTS INVOLVED. 2. THE INDIVIDUAL WHO WITNESSED THE ABUSE WILL REPORT THE SITUATION IMMEDIATELY TO HIS/HER SUPERVISOR. 4. THE STAFF MEMBER IN CHARGE WILL INITIATE THE INVESTIGATION IMMEDIATELY. 4. STAFF MEMBER (S) WILL MAINTAIN THE RESIDENT INITIATING THE ABUSE UNDER DIRECT SUPERVISION UNTIL THE INITIAL INVESTIGATION IS COMPLETE AND RESIDENT SAFETY IS MAINTAINED. 5. THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION. 6. THE CHARGE NURSE WILL ASSESS BOTH RESIDENTS INVOLVED TO DETERMINE IF PHYSICAL INJURIES HAVE OCCURRED a. RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT) ABOUT THE NATURE OF THE INCIDENT b. STATEMENTS WILL BE TAKEN FROM ANY ONE WITNESSING THE INCIDENT. 7. THE ATTENDING PHYSICIAN WILL BE NOTIFIED ... 8. THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED. 9. FOLLOW UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND RESIDENT (S) SAFETY IS MAINTAINED. 10. THE BEHAVIOR TEAM WILL ASSESS THE SITUATION AND MAKE RECOMMENDATIONS FOR FURTHER INTERVENTIONS.... IT IS THE RESPONSIBILITY OF THE ADMINISTRATOR/DIRECTOR OF NURSING TO REPORT THE ABUSE, OR ALLEGATIONS OF ABUSE, WITHIN 24 HOURS TO THE INDIANA STATE DEPARTMENT OF HEALTH....IF RESIDENT ABUSE IS IDENTIFIED OR SUSPECTED, THE FOLLOWING GUIDELINES WILL BE FOLLOWED: 1. ANY INDIVIDUAL WHO WITNESSES THE ABUSE, OR HAS SUSPICION OF, SHALL IMMEDIATELY NOTIFY THE CHARGE NURSE OF THE UNIT, WHICH THE RESIDENT RESIDES.... THE EXECUTIVE DIRECTOR AND/OR DIRECTOR OF NURSING WILL BE NOTIFIED OF THE REPORT AND THE INITIATION OF THE INVESTIGATION....THE RESIDENT (S) INVOLVED IN THE INCIDENT WILL BE ASSESSED FOR INJURIES....THE PHYSICIAN WILL BE NOTIFIED... THE FAMILY OF THE RESIDENT (S) AND/OR RESPONSIBLE PARTY WILL BE NOTIFIED....AN INCIDENT REPORT WILL BE INITIATED... ALONG WITH A NARRATIVE DESCRIPTION IN THE NURSES' NOTES....RESIDENTS WILL BE QUESTIONED (IF ALERT AND COMPETENT)ABOUT THE NATURE OF THE INCIDENT, AND THEIR STATEMENT WILL BE PUT IN WRITING....AN INVESTIGATION WILL BE DONE TO ASSURE OTHER RESIDENTS HAVE NOT BEEN AFFECTED BY THE INCIDENT OR INAPPROPRIATE BEHAVIOR, AND THE RESULTS DOCUMENTED....THE INVESTIGATION WILL INCLUDE: FACTS AND OBSERVATIONS BY INVOLVED EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING EMPLOYEES/FACTS AND OBSERVATIONS BY WITNESSING NON-EMPLOYEES/FACTS AND OBSERVATIONS FROM OTHERS WHO MIGHT HAVE PERTINENT INFORMATION/FACTS AND OBSERVATIONS BY THE SUPERVISOR OR INDIVIDUAL WHOM THE INITIAL REPORT WAS MADE...FOLLOW-UP ASSESSMENTS WILL BE COMPLETED/DOCUMENTED DURING EVERY SHIFT UNTIL THE RESIDENT (S) IS STABLE, AND THE RESIDENT SAFETY IS MAINTAINED....THE EXECUTIVE DIRECTOR OR THE DIRECTOR OF NURSING IS RESPONSIBLE FOR NOTIFYING THE FOLLOWING AGENCIES, AS OUTLINED IN THE 'UNUSUAL OCCURENCE REPORTING GUIDELINES' INDIANA STATE DEPARTMENT OF HEALTH/ADULT PROTECTIVE SERVICES/OMBUDSMAN/DIRECTOR OF OPERATIONSZXXXZZ