Every finding on record at Silvercrest Health and Rehabilitation Center

Based upon observations, interviews, and record reviews, the facility failed to ensure a dialysis resident received the appropriate care and medications for 1 out of 1 residents who received dialysis treatments. (Resident #60)The findings include:On 7/9/2026 at 10:30 AM, a record review for Resident #60 revealed he was admitted to the facility on [DATE] with the following diagnoses: End Stage Renal Failure. Renal Osteodystrophy, Disorders of Phosphorus metabolism, and Dependence on Dialysis treatments. Resident 60's current physician orders include Velphoro 500 mg chewable tablet every day (used to control high phosphorus) and Sevelamer Carbonate 800 mg give 2 tablets with meals (also used to control phosphorus levels).The record for Resident #60 revealed he was hospitalized on [DATE] with multiple falls at home and generalized muscle weakness. Resident #60 was discharged from the hospital on 5/30/26 and admitted to the facility. At the time of discharge, Resident #60 presented with a phosphorus level of 4.6 (which is considered high).The medication administration record and progress notes indicated that Resident #60 had not received the medication Velphoro for the entire month of June 2026 and July 2026, Sevelamer was administered per the resident's records on only seven out of the 24 days he was present in the month of June 2026. The progress notes on 7/5/26, 7/2/26, 7/1/26, 6/29/26, 6/27/26, 6/26/26, 6/15/26, 6/14/26, 6/12/26, and 6/10/26 stated, awaiting from pharmacy or medication not available. Medication administration record reports for all other missing days are documented as see progress notes, with no documentation actually in the progress notes. (photographic evidence obtained)On 7/6/2026 through 07/10/2026, multiple observations were conducted with Resident #60, who presented on non-dialysis days resting in bed, asleep, with no distress observed. Several interviews were attempted with Resident #60, however Resident #60 always stated he was tired or not feeling well after or before dialysis treatments and asked not to be interviewed.On 7/10/2026 at 08:18 AM, an interview was conducted with Staff Nurse A who indicated that Resident #60 will sleep most of the day after his dialysis treatments. When asked about his medication Velphoro not being administered, she stated, I don't know about the medication or why the pharmacy has not sent the medication, that's why I placed the medication on hold.On 7/10/2026 at 09:35 AM and interview was conducted by telephone with the Pharmacy Tech who revealed the medication Velphoro is not a mediation they are able to receive; however, the medication is available through the dialysis center where Resident #60 receives his treatments.On 7/10/2026 at 09:51 AM a follow up interview with Staff Member A revealed that the medication Velphoro was discontinued. When asked why the medication was discontinued, she stated that she wasn't sure.On 7/10/2026 at 12:10 PM, an interview with the dialysis center Clinical Manager revealed that she was unaware that Resident #60 was not receiving the medication as prescribed and was informed only today. She further stated the medication was on order for Velphoro and that the medication comes to the center and then we send the medication to the facility. She stated that it was ordered last week for a refill. She further stated it is very important for the overall health of Resident #60 to receive the necessary dialysis medication to assist in reducing the phosphorus from blood during treatments. She stated Resident #60's last phosphorus level was completed on 6/11/26 and resulted at a 7.3. which is higher than it should be for a dialysis patient. The medication Velphoro was initiated due to Resident #60 only eating two meals daily. She also stated that the medication Sevelamer should have been discontinued. Resident #60 has a diagnosis of Renal Osteodystrophy, which is a bone disorder caused by chronic kidney disease. It occurs when impaired kidney function disrupts the regulation of calcium, phosphorus, and vitamin D. Patients with this disorder may experience an increase in risk for fractures, skeletal deformities, bone pain, and muscle weakness. The management of this disorder consists of kidney transplant, dietary modifications, and medications such as phosphorus binders. (https://myclevelanclinic.org).

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 25 sampled residents to meet the residents nursing needs that are identified in the comprehensive assessment. (Resident #31 & #2) The findings include: Resident #31 On 04/21/25 at approximately 11:05 AM, Resident #31 was seen sitting in his wheelchair wearing a cardiac Life Vest (The LifeVest is a wearable cardiovascular defibrillator designed to protect individuals at risk of sudden cardiac death). A record review for Resident #31 revealed no orders for the cardiac Life Vest, and no mention of the cardiac Life Vest in the cardiac care plan. (photographic evidence obtained) On 04/23/25 at approximately 03:25 PM, an interview the Director of Nursing (DON) was conducted. The DON was asked what documentation is expected from nursing for a resident with a cardiac Life Vest. The DON stated there should be a cardiac care plan that would include the cardiac Life Vest. However, when shown that the cardiac care plan for Resident #31 did not contain language regarding the cardiac Life Vest, the DON stated, It should have been in the care plan. Resident #2 On 4/22/2025, a record review was conducted for Resident #2. The record indicated that Resident #2 was hospitalized on [DATE]-[DATE] with acute chronic respiratory infection. The physicians' orders included an order for Cefdinir Oral Capsule 300 MG (an antibiotic), give 300 mg by mouth two times a day for infection, ordered 3/28/25 and stopped 4/23/25. The care plan for Resident #2 did not include infection or antibiotic use. A review of Resident #2's diagnosis list included, ACUTE RESPIRATORY FAILURE WITH HYPOXIA and PNEUMONIA DUE TO METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS. The quarterly minimum data set (MDS) were positive for Infections (Pneumonia) and antibiotic use. On 04/23/25 at approximately 02:16 PM, an interview with Staff E, a registered nurse (RN)/MDS coordinator, was conducted about Resident #2's infection and if there should be a care plan for infection/antibiotic use. The RN/MDS coordinator stated Resident #2 has been in and out of the hospital lately for respiratory infections. She stated, Yes, she should have a care plan for infection, I must have missed this.

Based on family interview, record review, and staff interview, the facility failed to provide appropriate physician ordered services to increase range of motion or prevent further decrease in range of motion for 1 of 3 residents sampled for limited range of motion. (Resident #19) The findings include: A telephone interview was conducted with Resident #19's sister on 4/21/25 at 2:12 PM. She stated the resident had limited range of motion in his knees and was not receiving any services for the issue. A review of Resident #19's electronic medical record revealed a current physician order dated 1/28/25 stating to provide a functional maintenance program to provide stretching exercises to the bilateral knees while in bed to maintain knee extension. The current plan of care for Alteration in activities of daily living and Reduced range of motion with a diagnosis of bilateral knee contractures (revised 1/30/25) indicated that a functional maintenance program for knee stretches was started on 1/27/25 with a nursing intervention of range of motion to bilateral knees.A review of the task menu for April 2025 revealed no documented entries of the functional maintenance program and stretching exercises being performed as ordered. A review of the facility's Functional Maintenance Programs form for Resident #19, dated 1/10/25, revealed staff should stretch the resident's knees while in bed to maintain knee extension and prevent further contractures and verbally cue resident to improve standing posture when upright. An interview was conducted with Employee A (Registered Nurse) on 4/23/25 at 1:31 PM. Employee A stated she was in charge of the functional maintenance program. She stated that care is documented in the task menu. She reviewed the task documentation for Resident #19 and confirmed the care had not been documented as completed in the last 30 days. She then stated if it is not documented, the care had not been done.

Based on record review, interviews and facility policy review, the facility failed to provide medications at a timely manner for 1 of 3 residents receiving antibiotic medications via intravenous route. (Resident # 156) The findings include: On 4/21/25, Resident #156 had a pump used for intravenous therapy inside his room. On 4/21/25, Resident #156's medical records were reviewed. He was admitted to the facility on [DATE] following a stay at a hospital. Hospital records dated 4/4/25 indicated a physician discharge order to receive Ceftriaxone (a medication given to treat bacterial infections) 2 Grams (GM) daily for 14 days. Admission medication orders dated 4/4/25 stated to start Ceftriaxone 2 GM. Medication Administration Records (MAR) revealed Ceftriaxone's first dose was administered on 4/8/25. A progress note dated 4/5/25 explained that the medication was not at the facility. On 4/7/25, a progress note stated the pharmacy sent intravenous medications but was waiting for the pump to be delivered. On 4/23/25, a late note was entered into the electronic medical record indicating the reasons that antibiotic medication was delayed, due to the pharmacy needing clarification and pharmacy not delivering a pump for administration. On 4/23/25 at 9:42 AM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #156's medical records. She verified the resident did not receive the ordered antibiotics until 4/8/25, three days after the physician's orders. The DON stated she did an audit and asked Staff B, a Licensed Practical Nurse (LPN), about this. Staff B had told her that the person that had placed the first order had written to give 1 GM instead of 2 GM, and the pharmacy had requested clarification, delaying the delivery and subsequent administration. On 4/23/25 at 10:25 AM, an interview was conducted via telephone with the Pharmacy. They verified that the order for Ceftriaxone was received on 4/4/25, but the order read to use 1 GM and clarification was requested. They stated the clarification was received on 4/6/25. On 4/23/25 at 4:00 PM, an interview was conducted with the Medical Director. He stated it was unfortunate that the antibiotics were delayed for 3 days. The facility policy named Medication Delivery Expectations (dated October 2019) stated that the purpose was to ensure all residents will receive their medications as ordered and to ensure if medications was not received, center immediately intervene and medication is received within 4 hours.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts. The findings include: On 4/21/25 at approximately 11:47 AM, an observation was made of an unlocked and unattended medication cart. Four staff members walked by the unlocked medication cart between 11:47 AM and 11:49 AM, at which time the licensed practical nurse (LPN), Staff C, came out of a resident's room and acknowledged that he left the medication cart unlocked. On 04/24/25 at approximately 09:56 AM, the Assistant Director of Nursing (ADON) stated that the expectation is to lock the medication cart and computer screen when the nurse leaves the medication cart.

Based on record review and staff interview, the facility failed to designate a single code status in the medical record for 1 of 1 residents sampled for Advance Directives. (Resident #44) The findings include: On 2/7/24, a record review was conducted for Resident #44. The resident's record contained an active order for a Full Code dated 8/21/23 and an additional active Do Not Resuscitate (DNR) order dated 8/15/23. On 2/7/24 at approximately 1:17 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked who is responsible for entering the code status into the medical record. The DON indicated that the admitting nurse is responsible for entering the initial code status during admission and Social Services is responsible for verifying and updating the code status if necessary. On 2/7/24 at approximately 2:56 PM, an additional interview was conducted with the DON regarding active advance directive orders for Resident #44. The DON retrieved the medical record hard copy chart and reviewed the DNR yellow State of Florida form executed on 2/23/23. The DON indicated that Resident #44 is currently a DNR. The DON indicated the Full Code physician order should have been made inactive when Resident #44's code status changed from full code to DNR.

Based on observation, staff interview, and policy review, the facility failed to ensure staff perform appropriate hand hygiene in accordance with facility policy during 1 of 1 wound care observations. (Resident #101) The findings include: An observation of wound care for Resident #101 was conducted on 2/7/24 at 10:35 AM with the Assistant Director of Nursing (ADON). The ADON was observed to don a disposable gown, wash her hands, and apply clean gloves. She then removed the soiled dressing from the resident's sacrum and disposed of the dressing. She then cleansed the wound with the same gloves she used to remove the soiled dressing. She then washed her hands, applied new gloves, and applied the new wound dressing. Employee A did not wash or sanitize her hands after removing the soiled dressing and before cleansing the wound. An interview was conducted with the ADON on 2/7/24 at 11:37 AM. She stated she should have washed her hands and changed gloves after removing the soiled dressing and before cleansing the wound. Review of the facility policy for Non-Sterile Dressings (April 2019) revealed staff should wash or sanitize hands with alcohol based hand rub (ABHR), put on disposable exam gloves, loosen tape and remove soiled dressing, pull glove over dressing and discard into appropriate receptacle, wash hands or sanitize hands with ABHR (if not visibly), put on clean gloves, observe the wound and surrounding skin, cleanse the wound, use dry gauze to pat the wound dry, wash hands or sanitize hands with ABHR and apply new gloves, apply the ordered dressing and secure with tape.

Based on observation, interviews and record review, the facility failed to provide routine medications to meet the needs of 1 of 7 (#17) residents sampled for medication administration observation. The findings include: On 9/21/22 at approximately 1:50 PM, during a medication administration observation of Nurse A, a Licensed Practical Nurse (LPN), Resident #17 asked Nurse A about his inhaler medication and when it would be available. The nurse responded that the pharmacy stated it would be that evening. On 9/21/22 at approximately 1:50 PM, an interview was conducted with Resident #17 who reported he has not received his inhaler for almost a month now. On 9/21/22 at approximately 1:55 PM, an interview was conducted with Nurse A. Nurse A stated that the medication [MEDICATION(S)] Aerosol Powder Breath Activated 62.5 MCG/INH (a steroid inhalation medication used to treat [CONDITION(S)]) has been out for several days. She further stated that she notified the pharmacy, and when it did not come in, notified the Assistant Director of Nursing (ADON). When asked if the physician had been notified that Resident #17 had been without his medication for several days, Nurse A stated No. On 9/21/22 at approximately 2:00 PM, an interview was conducted with the ADON, a Registered Nurse. The ADON stated that she had called the pharmacy the other day to re-order the medication, and the pharmacy stated it would be delivered that night. She continued that, when it did not arrive, she called the pharmacy again the next day. When asked if the physician had been notified that the medication was out, the ADON stated that the primary nurse would have notified the physician, and confirmed that she had not done so. When asked about the facility's policy on re-ordering medication and notifying the physician, she stated she was not sure and would have to get back to the surveyor later with an answer to the question. A record review was conducted of Resident #17's electronic medical record. Review of the electronic medication administration record (EMAR) revealed that on the following dates, the medication Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH was documented as not given, 9/1/22, 9/3/22, 9/4/22, 9/8/22, 9/9/22, 9/12/22, 9/13/22, 9/14/22, 9/15/22, and 9/17/22. The EMAR revealed that the medication was documented as given on 9/2/22, 9/5/22, 9/6/22, 9/7/22, 9/10/22, 9/11/22, 9/16/22, 9/19/22, and 9/20/22. Review of the progress notes revealed no documentation that the physician was notified that the medication had not been given on 10 days. Further review of progress notes revealed that a progress note entered on 9/21/22 as a late entry for 9/19/22 revealed the pharmacy was notified of the medication not being delivered and the pharmacy reported it would be in that night. The note further indicated that on 9/20/22 the medication did not arrive and the resident requested the pharmacy be called again. On 9/21/22 at approximately 2:15 PM, an interview was conducted with the Nurse Consultant and the Director of Nursing (DON). When asked about the expectation for re-ordering medications from the pharmacy, the Nurse Consultant responded that if the medication is out, they need to notify the physician and obtain a hold order, then notify the DON to contact the pharmacy, and if needed have the back up pharmacy fill the prescription to be picked up by the facility. The DON stated that she was not notified of the medication being out. On 9/21/22 at approximately 3:30 PM, a telephone interview was conducted with the Pharmacy Manger and Pharmacist who stated that the last time the inhaler medication was delivered to the facility was on 8/19/22, and the medication was a 7-day supply. They stated they did not have any record of it being re-ordered prior to today, but that the medication is on the run tonight. A review was conducted of the document titled Medication Delivery Expectations. Under the Protocol subtitle, section E. states, if pharmacy refuses to deliver or pharmacy does not respond to call, immediately notify the Director of Nursing or Administrator. Section F. states, Administrator, DON, or designee to immediately notify pharmacy of any medication availability issues. If pharmacist does not respond to needs notify pharmacy manager. Do not stop until medication is received, even if that involves further escalating the situation. Section H. states, Notify physician if medication will be given late or obtain order for different start times if appropriate or request medication to be held until available or ask for a change in equivocal medication to one that is available.

Based on staff and resident interview, and record review the facility failed to provide Restorative Nursing Program services (RNP) post discharge from physical therapy per the plan of care for 1 of 1 resident sampled (#10). The findings include: On 6/28/21 at 12:13 PM, an interview was conducted with Resident #10. When asked about what concerns she had regarding her care she stated that she felt like she was in need of therapy because she could no longer walk. She stated that she was previously on rehabilitation services and was able to walk afterward, but had declined since then. A review was conducted of the Physical Therapy Discharge Summary. It stated that the resident had reached the highest practicable functional status and would be transferred to the Restorative Nursing program for continued work to increase walking distance from 50 feet to 150 feet. A review was conducted of the, Therapy Referral for Restorative Nursing Program - Caregiver instructions. It stated: Resident at risk for decline in strength affecting ability to ambulate. Overall goal of restorative program: Increase endurance for ambulation from 50 feet to 150 feet to enable resident to reach shower room or scale to be weighed. Care giver training: Ambulate with resident utilizing roller walker with wheelchair to follow for distances up to 50 feet gradually increasing distance. Precautions and comments: Verbal cueing to decrease shuffling gait pattern. Caregiver training log: 5/19/2021 - The trainer was Physical Therapy Assistant B. Staff signed as trained: Certified Nursing Assistant A A review was conducted of the documentation for the Restorative Nursing Program. The stated order in the documentation was, RNP for walking. Resident will increase endurance for ambulation from 50ft to 150ft to enable resident to reach shower room or scale to be weighed on days and evenings. This was documented as completed on: 5/30 at 9:48 AM 6/8/2021 at 11:31 AM and 9:12 PM 6/10/2021 at 9:3 PM 6/12/2021 at 9:03 PM 6/22/2021 at 8:53 PM 6/24/2021 at 5:09 PM 6/25/2021 at 2:59 PM It was documented as not completed on: 6/1/2021 at 21:00 (9::00 PM) 6/3/2021 at 11:37 and 21:17 (9:17 PM) 6/4/2021 at 14:59 and 20:59 (8:59 PM) 6/5/2021 at 11:36 and 16:58 (4:58 PM) 6/6/2021at 09:43 and 16:58 (4:58 PM) 6/7/2021 at 21:24 (9:24 PM) 6/9/2021 at 21:43 (9:43 PM) 6/11/2021 at 11:33 and 16:17 (4:17 PM) 6/13/2021 at 21:07 (9:17 PM) 6/14/2021 at 21:39 (9:39 PM) 6/15/2021 at 14:59 and 20:35 (8:35 PM) 6/18/2021 at 21:36 (9:36 PM) 6/21/2021 at 22:58 (10:58 PM) 6/23/2021 at 14:59 (2:59 PM) 6/24/2021 at 14:59 (2:59 PM) It was documented as not applicable on: 6/10/2021 at 15:59 (3:59 PM) 6/18/2021 at 14:59 (2:59 PM) 6/26/2021 at 10:15 and 22:28 (10:28 PM) 6/27/2021 at 13:21 and 15:54 (3:54 PM) There was no documentation at all on: 5/31/2021 6/2/2021 6/16/2021 6/17/2021 6/19/2021 6/20/2021 And it was documented as refused on: 6/5/2021 at 16:58 (4:58 PM) 6/6/2021 at 16:58 (4:58 PM) 6/11/2021 at 16:17 (4:17 PM) 6/14/2021 at 21:39 (9:39 PM) A review was conducted of Resident #10's care plan which revealed a care plan with a focus of: Resident (#10) has an alteration in activities of daily living function as evidenced by her needing assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene, related to weakness, recent hospitalization , shortness of breath, and end-stage [CONDITION(S)]. She also has history of right hemi paresis (partially paralyzed on one side of the body) and spinal stenosis and [CONDITION(S)] disc disease to lumbosacral spine. One of the listed interventions was, Restorative Nursing Program as ordered. On 6/30/21 at 9:45 AM, an interview was conducted with the Restorative Program Manager. When asked how the process works when transitioning from physical therapy to restorative she stated that when discharging from therapy, the therapy department would send her the Restorative Program that they outlined and she was responsible to putting the order into the electronic medical record. From there the therapy staff would meet with the floor staff to do training on the program and the timing. She stated that she periodically monitored on a monthly basis and would report back any changed to the therapy team. From the system the floor certified nursing assistants (CNA) can find the restorative order in the CNA taskbar. She stated that the facility did not have dedicated restorative staff, but instead the floor staff are responsible for carrying out the orders during their regular care. If a decline was noted she stated that either the floor staff themselves or she could speak with therapy to get another evaluation to determine what to do. When asked about the above documentation showing that the interventions were not being carried out she stated that there were some new staff and that therapy had spoken to the staff regarding the appropriate documentation of restorative interventions. She agreed to have physical therapy complete an evaluation to determine the residents current functional status and report back to the surveyor. She also stated that since the start of COVID19 staffing issues have come and gone as well and that may have played a part. On 6/30/21 at 10:13 AM, an interview was conducted with CNA A (Hire date of 1/26/2021). When asked about the restorative program for Resident #10 she stated that at one point the resident was in therapy, but was not sure if that was an ongoing intervention for the resident. When asked about whether she assisted the resident to do any walking she stated that if the resident wanted to get up, she would check with the resident and that she helped her walk back and forth from the bathroom. She did say that the resident does not walk much in the hall. At 10:15 AM, Restorative Aide C entered the interview and stated that when a Restorative Nursing Program is initiated it is the floor staff that are responsible for implementing the interventions and that the CNAs should be helping the resident walk. She stated that she does wonderful with cueing. She further stated that at the beginning of the program the floor staff are trained in the specific program for that resident and stated that they sign off that they were trained and understand. On 6/30/21 at 10:23 AM, an interview was conducted with the Director of Rehabilitation Services. She stated that when a program starts, she has the Restorative Program Manager put in the orders. She stated that then they train the nursing staff how to complete program interventions. She stated that when the training is completed they have the staff sign at the bottom of the program signaling understanding. She produced the form which was signed by CNA A. On 6/30/21 at 10:57 AM, after reviewing the form it was brought to CNA A. She agreed that it was her signature on the restorative education plan and agreed that the plan stated that the resident was to walk 50 feet to 150 feet to enable resident to reach the shower room or scale to be weighed. A review was conducted of the Physical therapy evaluation completed on 6/30/2021. At that time it was determined that the resident did not loose any function and had met her goals of the restorative program and would be transferred to a Functional Maintenance Program. A review was conducted of the, Nursing Restorative/Rehabilitation Manual May 2013, in the, Nursing Services Procedures, dated August 2015. Under the title, Restorative Nursing Quick Reference Guide: items 11-15 included: 11. Discuss residents daily in the PPS meetings 12. Update goals every month and document summary of resident's progress for the month 13. Decided if resident will continue to benefit from program 14. Continue to talk with the entire Team and Skilled Therapy about resident's progress and/or problems (i.e. refusals, unsteady gait, sob) 15. Discharge the resident to the floor staff once goals are met, resident is no longer making progress, refuses (Amount of time needed on any program is resident specific and can be days. weeks or even months) or is not able to continue due to acute illness, etc. Under the title, Program Forms, under the sub-heading, Communication to Caregivers, it stated, When the caregivers sign their names, titles and initials on the form (below the goal section), they are indicating that they have been instructed in the program for the specific resident, and that they understand the level of assistance, treatment precautions, specific approaches for the resident. The next sections title was, Accurate recording of treatment minutes, which stated, Treatment must be documented in accurate, actual minutes provided. If the resident cannot perform the required minimum of 15 minutes and he/she is capable of participating later in the day, it is expected that caregivers will return to provide the care to benefit the resident. Reasons why documentation must be 'real' minutes. It is an honest accounting (and a corporate compliance issue). Very often when residents experience changes in function or condition, it will be demonstrated in their functional performances. Documenting true-time participation establishes supportive documentation for that change of function and/or referral to skilled therapy. Documenting exceptions - Caregivers should document exceptions (i.e. refusals, sick, etc.) by using the keys provided. When an exception occurs, it should be immediately reported to the program manager/designer for following up.

Based on interview with the Minimum Data Set (MDS) Nurse, record review and review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0, the facility failed to accurately record the assessment for 4 of 18 residents sampled (#17, #12, #31, and #52). The findings include: Resident #17 A review of Resident #17's Admission Assessment, from 9/30/2019, was conducted. Under section N0410E Anticoagulants, the assessment coded that the resident received an anticoagulant for 7 days of the look back period (the look-back period counts back 7 days from the most recent admission/entry or re-entry). A review of Resident #17's physician's orders [REDACTED]. On 12/18/19 at 12:50 PM, an interview was conducted with Nurse C. She was asked to pull up the assessment from 9/30/2019 and navigate to section N. She agreed at that time the resident was coded as having received an anticoagulant for 7 days of the lookback period. She was then asked to identify the medication she received during that time period that was an anticoagulant. She looked through the orders and stated that the resident was on [MEDICATION NAME] (an antiplatelet medication). She was then asked if she had a reference manual for completing the assessment. She stated that it is in the computer when you fill out the assessment. She was asked to bring up this guidance. She read aloud that antiplatelet medications, such as [MEDICATION NAME], should not be coded as anticoagulants. A review was conducted of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0 was conducted. In Chapter 3, under section N, on page N-5 under the heading, Coding Instruction, the manual stated, Check E, anticoagulant if anticoagulant medication was received by the resident at any time during the 7-day lookback period. Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME] or [MEDICATION NAME] ([MEDICATION NAME]) here. Resident #12 A review of Resident #12's MDS dated [DATE] was conducted. Under section K0510 Oral/Nutritional Status the assessment indicated Resident #12 had an enteral feeding tube. A review of Resident #12's physician's orders [REDACTED]. On 12/18/2019 at approximately 1:45 PM, an interview was conducted with Nurse C, the MDS Coordinator during which she was asked to look up Resident #12's MDS assessment from 10/03/2019 and navigate to section K Oral/Nutritional Status. She said an MDS error had occurred, determined the resident did not have a feeding tube. Resident #31 A review of Resident #31's MDS dated [DATE] Section B100 lists the resident's vision as adequate. A record review was conducted for Resident #31 which revealed the resident had a [DIAGNOSES REDACTED]. On 1216/19 at 10:32 AM, an interview was conducted with sitter working with Resident #31 during which she stated He blind in one eye and he has a cataract in the other. I help him locate things when he has trouble. On 12/17/19 at 02:18 PM, an interview was conducted with the MDS Coordinator, during which she was asked Why is vision listed as adequate in section B of MDS dated [DATE]? Nurse C replied: I do not do that part of the MDS social services does that On 12/18/19 at 11:10 AM, an interview was conducted with the Social Services Coordinator, during which she was asked: Why is vision listed as adequate in section B of MDS dated [DATE]? The Social Services Coordinator replied: Yes that was done in error. It may have been clicked on in error. Resident #52 A record review was conducted for Resident #52 which revealed she was admitted to the facility on [DATE] and was discharged on [DATE] with return not anticipated. A review of the MDS Section A 2100 Discharge Status revealed the section was coded as 03 acute care hospital. The MDS Coordinator Employee C was interviewed on 12/19/19 at 09:26 AM. She was asked about the status of Resident # 52. She reviewed the electronic record. She said she did go home, and then stated, I coded that incorrectly.

Based on observation, staff interview, and policy review the facility failed to prevent the possible indirect transmission of infection during observed suprapubic catheter care for 1 of 1 residents sampled (Resident #31). The findings include: On 12/17/19 at 3:29 PM, an observation was made of Nurse D performing suprapubic catheter care for resident #31. During the procedure Nurse D cleansed around the suprapubic area with a gloved hand and then used this hand to pull the light cord. After pulling the cord she immediately resumed cleansing around the catheter, at no point was she observed to change her gloves or wash her hands. On 12/17/19 at 3:40 PM, an interview was conducted with Nurse D regarding suprapubic catheter care. When asked about pulling the light cord and resuming catheter care with contaminated gloves she stated 'Yes, I should not have done that. On 12/18/19 at 11:15 AM, an interview was conducted with the Staff Development Coordinator during which she stated We have not recently done training for suprapubic catheter care. I will get training done soon. On 12/19/19 a review was conducted of the facility policy, Handwashing Policy, dated (MONTH) (YEAR), which stated that handwashing should occur after handling items potentially contaminated with blood body fluids, excretions, or secretions.

Based on numerous resident and staff interviews, resident council meeting minutes and review of the State staffing worksheet and employee schedule, the facility failed to ensure sufficient nursing staff in order to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 of 16 residents. (Residents #18, #27, #32, #36, #41 and #52) The findings included: On 01/22/19 at approximately 11:00 AM, Resident #36 was interviewed and stated,they only have 1 CNA on this side of the hall, that's too much for one person. He stated he has had to wait over 45 minutes for someone to respond when he has rang his call light. The resident stated he gets his showers, only because he 'stays on them' about that, but shower times are getting later and later. He receives his showers on 7-3 shift. On 01/22/19 at approximately 11:20 AM, Resident #32 was interviewed while she was in bed. She stated she only gets one shower a week, other than that she gets bed baths. She would like more showers. On 01/22/19 at approximately 2:55 PM, Resident #18's family member stated there is not enough staffing, no particular shift. She stated that all that was asked was that her mother be kept clean, dry and fed. The family member complained that she has come in to find her mother soiled. She doesn't think they have enough CNAs (Certified Nursing Assistants.) On 01/22/19 at approximately 03:20 PM , an interview was completed with Resident #41. Resident #41 complained of there not being enough staff. Resident #41 stated there were long wait times when ringing the call bell and she was not being offered her shower. Resident #41 stated she didn't get her Shower last Saturday and it wasn't until she complained that she did get it the next day. She said, Residents shouldn't have to complain to get their showers. On 01/24/19M at approximately 10:00 AM, the resident reported that she did not get her shower yesterday. On 01/23/19 at approximately 07:36am, an interview completed by Surveyor # and the Risk Manager, stated that Resident #7 had reported to her that he has not been getting his showers. She stated the staff get too busy to give him a shower on his scheduled bath days and that showers might not be done until the next night. On 01/23/19 at approximately 09:15 AM, Resident #27 was interviewed and complained that there was not enough staff here to help her walk. She stated she met her goals in Physical Therapy and she still wants to work on walking and was told that staff would assist her with walking. Resident #27, stated that staff are just too busy, and they don't have time to walk her. A review of the Resident's medical record, revealed she was discharged from the Restorative Nursing Program after 3 weeks, after meeting her goal. On 01/24/19 beginning around 09:30 AM, an interview was conducted with Staff M. Staff M was not assigned to a particular hall, but helps out where needed. Staff M stated she has heard residents complain about not getting a shower, and said when she hears this, she offers to give them a shower and then let the nurses know. Staff M stated she has spoken to the Staffing Coordinator and the Assistant Director of Nursing about this. Staff M stated that CNAs are assigned halls. Staff M stated the facility has 3 halls. They staff normally two CNAs on each side. She said, the 400 hall has only 12 patients, so this hall can be run with 1 CNA, but if they have an extra CNA they put 2 CNAs on that hall, the 500 hall has 24 patients and staff with 2 CNAS, and the 300 hall has 22 patients and is staffed with 2 CNAs. She stated that the 11 - 7 shift has 4 CNAs, 1 on each hall and then 1 CNA that floats. Staff M stated the CNA duties include: 1st shift - feeding, bathing, getting people up,changing them, vital signs on those that need, and put back to bed after lunch, and pass ice. 2nd shift - gets back up for dining. Showers, vital signs, pass ice and do night time dining room and help feed residents. 3rd shift - check and change residents, obtain vital signs and pass ice, clean wheelchairs and then get residents up in the morning. On 01/24/19 at approximately 09:50 AM, an interview was conducted with Staff N. Staff N stated her duties included: staffing, stating that they typically have morning (standup) and talk about admission and discharges and review Medicare and Medicaid residents. She said they staff according to the census. They periodically update their staffing sheet to make sure they are meeting the number of hours, this information is corresponded with the person in Admissions. They project staffing for the following day. Staff Member N stated they DO NOT NECESSARILY staff based on acuity of the resident. On 01/24/19 at approximately 10:15am, with the assistance of Staff O, an extensive review of the facility's staffing schedule compared to the State Staffing worksheet was completed. The State Staffing Worksheet for 01/06 through 01/19/19 revealed 2 of the 14 days (1/06 and 01/14) with staffing levels well below the State allowable minimum for CNA hours. The days were not consecutive. The majority of other days, revealed numbers just at or slightly above the minimum number of CNA hours required. This prompted a review of the staffing schedules and timesheets. The review identified many CNAs working double shifts or extended shifts, and licensed staff being scheduled to work as CNAs (without a specific assignment). The facility was not able to demonstrate what assignment staff were given to ensure the provision of care to residents. On 01/24/19 at 2:55 PM, an interview was conducted with Staff Member P. She stated the facility was short staff and that there have been days that they have not been able to get showers and other tasks completed. They have complained to Adminsitration and have been told they are meeting the staffing numbers. On 01/24/19 at approximately 3:15 PM, an interview was conducted with Staff Member Q. She stated she has had over 110 hours in one pay period. She works a lot of double shifts. She stated they were not staffed well and that she often does not have time to get everything completed for the resident. She said, residents need to be fed and sometimes have to wait to be fed because there was not enough staff. She also stated that residents also have gone without showers because there was not enough staff to be able to get to it. On 01/24/19 at approximately 04:55 PM by Surveyor # , an interview was conducted with the Social Services/Activities Director during which she stated that when the Resident Council has a complaint she reports it to the department heads and it is addressed with the staff. She stated that a follow up to any concern would be offered in the next meeting and this was documented in the resident council minutes. She stated there have been concerns related to showers and the facility was working on the issues. The facility had created a shower team which was effective, but it hasn't been done lately because of low staff. She also reported they were working on a new shower schedule, but again stated that with the low staffing this has not been implemented. On 01/25/19 at approximately 09:15 AM, an interview was conducted with Staff Member R who was helping out for the day. She stated she normally works 11-7 shift and often works doubles. Staff Member R indicated staffing was okay on the night shift, but during the 7-3 shift there was not enough staffing to provide all the needed care for residents. She stated that residents on occasion do not receive showers because she just does not have time. On 01/25/19 at approximately 09:20 AM, an interview was conducted with Staff Members S and T. Staff Members indicated that they were not always able to provide all the care to residents that they need which included walking and showering/bathing residents. Staff T stated they need more help.

Based on interview and record review, the facility failed to respond to grievances and recommendations voiced by the Resident Council for 4 of the last 4 meetings held (September (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR)). The findings included: On (MONTH) 23, 2019 at 1:00 PM, a Resident Council Meeting was conducted. In attendance were the Resident Council Vice-President along with 9 additional council members who regularly attend the monthly resident council meetings. The residents stated meetings are held monthly and the facility's Activities/Social Services Director attends and takes minutes. The council stated they have voiced several concerns related to the facility being short staffed and they were not getting showers on their assigned shower days or at all for some. They revealed this had been discussed at several of the meetings however nothing had been done about the concern. A review of the Resident Council Minutes found that the shower concerns are documented within the resident council minutes for September, October, (MONTH) and (MONTH) (YEAR). There was no documentation related to follow up or the concerns being addressed. On 01/24/19 at approximately 04:55 PM, an interview was conducted with the Social Services/Activities Director, in which she stated that when the Resident Council had a complaint she reported it to the department heads and it was addressed with the staff. She stated that a follow up to any concern was offered in the next meeting and this would be documented in the resident council minutes. She stated there have been concerns related to showers and the facility was working on the issues. The facility had created a shower team which was effective, but it hasn't been done lately because of low staff. She also reported they were working on a new shower schedule, but again stated that with the low staffing this has not been implemented. She stated she meets privately with any resident who voices a concern during the meeting and asks them if they want to file a grievance, but that there really have not been any major issues that require a one. She reported that she did not feel the shower concerns were consistent enough to warrant a grievance report because when she would attempt to follow up with the individual residents they would have received a shower so she felt their issue was resolved. Review of the Resident Grievance Program Policy revealed In case of a verbal grievance, the person receiving the grievance will document the grievance on the Grievance Report.

Based on staff interview and clinical record review the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission for 2 of 2 residents (#154 and #23) The findings included: Resident #154 Resident # 154 was admitted to the facility on [DATE] post hospitalization for displaced [MEDICAL CONDITION] femur. A review of the resident's chart revealed a form that says Baseline Care Plan. The form was blank. An interview was conducted with Employee K, Risk Manager, on 1/24/19 at approxiamtely 3:00 pm. She was asked who completed the baseline care plan. She replied admissions. She was asked to find the care plan in the chart. She saw the blank form in the chart and said that if her care plan has been initiated in electronic chart then we do not need it. She was then asked to pull up the electronic record care plan which was dated 1/6/19. Employee K was asked if the baseline care plan had been completed in the required 48 hours and she said, No. This surveyor returned to the conference room and pulled up the resident's care plan electronically. Resident #154 was observed to have one care plan which was dated 1/4/19 for risk of antidepressants, the others were again observed to be initiated on 1/6/19. Resident #23 A review of the clinical record for Resident #23 was reviewed. He was re-admitted to the facility on [DATE]. He was found to have a baseline care plan dated 1/23/19. On 1/25/19 at approximately 8:50 am, Employee K was interviewed regarding Resident #23. She was asked if the care plan had been signed by the resident or the family representative she said, No. The Assistant Director of Nursing was interviewed on 1/25/19 at approximately 8:58 am. She was asked to look up the date of the baseline care plan. She said it was signed on 1/23/19.

Based on record review, staff interview and facility policy review, the facility failed to establish and implement the Plan of Care for 3 of 16 residents reviewed for Care Plans (#13, 52, and 36). The findings included: Resident #13 A record review was conducted for resident #13, which revealed she was admitted to the facility in (MONTH) of (YEAR) with orders for hospice services. Review of the Care Plan found there to be no indication that the resident was receiving hospice care despite the Resident Assessment completed on admission identifying her as receiving end of life care. On 1/24/19 at approximately 11:09 AM, an interview was conducted with the MDS (Minimum Data Set) Coordinator in which she stated that the resident was admitted with hospice services and the MDS was coded as such however this was not indicated on the Care Plan which was developed by the Assistant Director of Nursing (ADON). On 1/24/19 at approximately 12:48 PM, an interview was conducted with the ADON. She stated that the MDS Coordinator, the Risk Manager and the ADON were responsible for updating the Care Plan to include hospice and indicated this had not been done for resident #13 stating It should have been caught. Resident #52 A record review was conducted for resident #52 which revealed she was receiving [MEDICAL TREATMENT] via a fistula in her left upper arm three times a week. Review of the plan of care for this resident revealed a care plan for Risk for complications due to [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) and (MONTH) (YEAR) found documentation of the fistula assessment every shift until the resident was admitted to the hospital on (MONTH) 16, (YEAR). When the resident returned to the facility on [DATE] all documentation on the MAR resumed with exception of the fistula assessments. On 01/24/19 at approximately 12:35 PM, an interview was conducted with the Assistant Director of Nursing (ADON), in which she stated the resident was sent to the hospital on [DATE] and upon her return the order to assess the fistula was not put back on the MAR. She stated that even though it appeared the Plan of Care since (YEAR), and was documented, it was not required to assess the fistula every shift only on the days the resident goes to [MEDICAL TREATMENT]. It was noted that after this interview an order was placed in the chart to assess the fistula every shift. On 1/24/19 at approximately 3:05 PM, an interview was conducted with staff member B, an Licensed Practical Nurse (LPN), in which she stated that [MEDICAL TREATMENT] fistulas should be assessed every shift and documented on the MAR. On 1/24/19 at approximately 3:06 PM an interview was conducted with staff member C, an LPN, in which she stated that [MEDICAL TREATMENT] fistulas were assessed every shift and documented in the Electronic Medical Record (EMR). Resident #36 A review of Resident #36's care plan entitled Impaired skin integrity related to [MEDICAL CONDITION], decreased mobility, discoloration of skin related to poor circulation, dry skin and [DIAGNOSES REDACTED]. Administer treatments as ordered. Observe for effectiveness. CNA to provide skin checks during delivery of care. [MEDICATION NAME] Shampoo 2% ordered for scalp irritation as resident requests. Provide pressure reduction devices as indicated. On 01/22/2019 at approximately 12:00pm, Resident #36 was observed and interviewed regarding his lower leg skin condition and [MEDICAL CONDITION]. He stated he was not on any physician prescribed treatment. He stated he saw a Dermatologist last year, who prescribed moisturizing lotion, but the facility ran out and no longer applied it. A review of Resident #36's medical record revealed Physician Orders, dated 10/30/2018 for [MEDICATION NAME] 2% Shampoo. Shampoo in hair 3-4 times per week. Lather in scalp and face, let sit 5-10 minutes, then rinse and Mupirocin 2% topical ointment - Apply to wound on left leg, twice a day until completely healed. There were no discontinuation orders noted. A review of Resident #36's Medication Administration Record (MAR) failed to include the prescribed treatments ([MEDICATION NAME] and Mupirocin.). The Resident's Treatment Administration Record (TAR), included the order [MEDICATION NAME] Shampoo 2% - Apply to hair, face, body topically every evening shift for fungal lather in scalp, body and face, let sit -5-10 minutes rinse with shower. There was no entry for the Mupirocin 2% topical ointment. The TAR for (MONTH) 2019 revealed an entry every day for the entire month, referencing the code 4, a refusal on 01/06/2019 and treatment given on 01/17/2019. The code 4 indicated to see Nurse's notes. There was no physician order to indicate the Mupirocin 2% was discontinued or that the lower legs were healed. A review of Resident #36's Nursing progress notes, repeatedly documented Note Text: [MEDICATION NAME] Shampoo 2% Resident did not shower today or Not resident's shower day for the month of (MONTH) 2019. On 01/24/2019 at approximately 3:00pm, an interview was conducted with Resident #36. The resident was asked if he had been receiving showers in the evening where staff applied the [MEDICATION NAME] Shampoo to his scalp, head and body? The resident had no idea what the surveyor was talking about. The resident stated he gets his shower On Mondays, Wednesdays and Saturdays on the day shift and staff use the shampoo that his wife bought him (points to a bottle of shampoo on his nightstand.) He stated he gets no treatment to his lower legs, other than the Curel lotion his wife brings him from home. On 01/25/2019 at approximately at 9:50am, an interview was conducted with Staff T who worked with Resident #36. Staff T was not aware of any special shampoo that the resident used on his scalp.

Based on interview and resident medical record review, the facility failed to ensure adequate monitoring of medicatiom for 1 of 6 residents reviewed for Unnecessary Medication (Resident #36). The findings included: On 01/22/19 at approximately 12:00pm, Resident #36 was observed to have significant (4+) pedal [MEDICAL CONDITION] bilaterally. The resident was interviewed and stated that it has gotten worse and that bloodwork had been drawn yesterday. The resident stated he takes a diuretic and has heart issues. Physician orders [REDACTED]. Results of Resident #36's lab work, drawn on 01/21/2019 identified an elevated potassium level of 5.4 (normal 3.5-5.0 milliEquivalents per liter). The bottom of the lab report documented the physician was notified of results on 01/22/2019 and orders were received to discontinue [MEDICATION NAME] (a diuretic which also helps to reduce potassium) and [MEDICATION NAME] (a blood pressure medication that can increase blood potassium levels). Repeated bloodwork was ordered for Friday, 01/25/2019. On 01/25/2019, a review of Resident #36's Medication Administration Record, [REDACTED]. On 01/25/2019 at approximately 9:30am, an interview was conducted with the facility's Assistant Director of Nursing and she was not aware the resident remained on potassium chloride, but knew medications had been discontinued because of an elevated potassium level. The ADON stated the resident was getting repeat bloodwork that morning. The facility failed to identify and correlate the Resident's elevated potassium level, and his continued administerstration of Potassium Chloride (potassium replacement) and failed to ensure that the physician was made aware the resident was on Potassium.

Based on observation, interview and policy review the facility failed to ensure that expired medications were removed from medication carts and that medications provided by the family of residents were labeled appropriately for 1 of 2 medications carts observed. The findings included: On 01/25/19 at approximately 08:43 AM, an inspection of the nurse Medication Cart for the 500 hall was conducted. During this review a clear plastic Ziploc baggy was observed to have 5 [MEDICATION NAME] 5% patches with resident #48's name written in blue ink on each patch. Neither the bag nor the patches had a facility issued resident's label nor was there indication of the physician's instruction for use. Further review of the patches found that 2 of the patches had a product expiration date of 05 / (YEAR). An interview conducted with staff member A, an LPN, at the time of the observation revealed that she had applied a [MEDICATION NAME] to resident #48 this morning. Together with the surveyor the patch on the resident was observed and dated 1/25/19. In an empty garbage can in the resident's room an open discarded 5% [MEDICATION NAME] with an expiration date of 05/2016 was found. The nurse at that time immediately removed the patch from the resident's back. Review of the MAR for resident #48 found a physician's orders [REDACTED]. The MAR indicated [REDACTED]. Review of the policy Storage of Medications dated Nov (YEAR) indicated that No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this center. All such drugs are destroyed. Review of the policy Acceptance of Medications on admitted d Nov (YEAR) indicated that Medications examined and approved for the resident's use must be properly labeled in accordance with our established polices governing the labeling of medications and medications which are accepted, but do not meet the labeling requirements, must be forwarded to the pharmacy for proper labeling prior to the administration of such medicines Review of the policy Administration of Drugs dated Nov (YEAR) revealed Prior to administering the resident's drug, the nurse should compare the drug and dosage schedule on the resident's MAR indicated [REDACTED]

Based on observation, interview and review of the facility's policy and procedure, the facility failed to ensure hand-hygiene was performed prior to performing wound care and during wound care for 1 of 1 residents observed with pressure ulcers. (Resident #11). The findings included: On 01/25/2019 beginning at approximately 10:40am, wound care was observed for resident #11, performed by the Staff Member K. Staff Member K failed to perform hand hygiene prior to beginning wound care and prior to going from a dirty to clean area of the wound. This was confirmed with Staff Member K following the treatment. A review of the facility's policy and procedure for Hand Hygiene indicated that 2. Associates must perform appropriate handwashing procedures under the following conditions: e. Before handling clean or soiled dressing, gauze pads, etc. f. After handling used dressings, contaminated equipment, etc.; j. After removing gloves and .m. Upon completion of duty. 3. The use of gloves does not replace handwashing.

Based on resident and staff interview and record review, the facility failed to provide a written notice of transfer to the resident and the resident's representative for 1 of 2 residents reviewed for hospitalization s (#16). The findings are: Resident #16 was briefly interviewed on 2/13/18 about 1:25 pm and stated, I just got back from the hospital yesterday. I had pneumonia. A review of the chart revealed bed hold policy, and interim care plan for return to the facility. Electronic record review revealed that the resident was sent to the hospital on [DATE] with symptoms of upper respiratory infection and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Director of Nursing (DON) was interviewed on 2/14/18 about 1:30 pm regarding paperwork required before residents were transferred to the hospital. Explained all the paperwork that would go with the resident for medical purposes and contacting the medical doctor and family. She said they would also let the Ombudsman know monthly the residents that went to the hospital. The February list to the Ombudsman showed resident #16 listed. The regulation was reviewed with her about giving notice of transfer in writing to the resident/and or the family. The consultant nurse came to ask exactly what was needed on 2/14/18 about 1:45 pm and an explanation was given to her as well. A follow-up was conducted with the consultant nurse at 3:00 pm. She confirmed that the written notification to resident #16, regarding her transfer to the hospital, was not done.

Based on resident and staff interview, and resident record review the facility failed to have a process in place to determine the preferred bathing schedules for 2 of 21 residents interviewed (#46 and #79) and 1 of 2 family interviews (#83). The findings are: Resident #46 was interviewed on 2/27/17 about 3:40 pm. When asked if she had a choice about the number of showers she wanted per week, she stated,No. She then confirmed that she received showers three times per week, but stated, I would like to have a shower when I want a shower not when they tell me. She said she needed assistance in the shower, which was confirmed through review of her quarterly Minimum Data Set (MDS) completed on 1/29/17 that indicated she required one person physical assist with bathing. An interview was conducted with resident # 79 on 2/27/17 at 11:20 am. He was asked if he had a choice about the number of times he took a bath or shower, and he stated, No. He then said, 'they tell me how often, which is two times a week. I would like to be bathed three times a week. No one has asked me how often I want to be bathed. His admission MDS dated [DATE] indicated he needed one person physical assist with bathing. Resident #83 did not feel like being interviewed, but consented to have her daughter answer questions for a family interview on 2/27/17 at 1:38 pm. Her daughter stated that she would like to her mother to be bathed at least three times a week, but she was scheduled to be bathed on Tuesdays and Thursdays. The resident's 30 day MDS assessment dated [DATE] showed she needed one person physical assist for bathing. An interview was conducted with the Licensed Practical Nurse (LPN) Employee A on 2/28/17 at 3:40 pm. When she was asked about the bathing schedules she said residents were bathed twice weekly unless they request to be bathed more often or if the family specified otherwise. She then directed this surveyor to a bathing book which broke down bathing schedules to rooms and day shift or evening shift. The CNA (Certified Nursing Assistant) Employee B was interviewed on 2/28/17 at 3:54 pm. She also said showers were twice a week, and were split between day and evening shift. An interview was conducted with the Director of Nursing (DON) on 2/28/17 at 4:00 pm. She was asked the process for determining how often a resident would like to be bathed. She said showers were normally given twice a week according to the resident's room number; however, residents could tell tell the facility if they wanted it adjusted. The Social Worker was interviewed on 3/1/17 about 10:10 am . She said she completed the preference section of the MDS (Section F). The preference section is done on admission, significant changes, and yearly for long term care residents. she stated she asked residents about their previous activities, use of devices, if they manage their own affairs, and about their bathing routine at home. She confirmed that this information was not documented anywhere, but she did tell resident's the bathing schedule of the facility being twice a week. She stated that if the resident wanted a different schedule, she would give that information directly to the DON.

Based on resident and staff interviews and record review, the facility failed to ensure that 3 of 60 facility residents were free of verbal or physical abuse (#8, 23, and 69). Multiple staff members had been made aware of intentional rudeness, refusal of care and services, and rough physical treatment of [REDACTED]. Staff did not report these incidents to appropriate state agencies, alleged perpetrators were not removed from the facility pending investigation, and the facility did not conduct a thorough investigation. The facility failure to identify, protect, investigate and report allegations of abuse led to a determination of Ongoing Immediate Jeopardy. The facility was informed of the finding of immediate Jeopardy on 10/19/12. The findings are: Interview with resident #69 on 10/17/2012 at 2:14 PM revealed an affirmative answer when he was asked if staff had ever been physically rough with him or rude to him. The resident stated he defines abuse as banging up on folks or not feeding them on time and or not feeding them at all, not helping them when they need help, or it could be seeing someone fall down and not helping them up. He stated that recently "I had my own experience with it. I have [MEDICAL CONDITION] and needed some help. When you need to go to the bathroom you need to go to the bathroom. I told two staff girls when I needed help with going to the bathroom. The CNA (Certified Nursing Assistant) told me I could do it myself. That girl pushed me in the wheelchair into the wall and then shoved me back into the wall and I hit the wall. One told me to move my feet but when you are locked in you are locked in and can't move. She ran over my feet." He stated he and his POA (Power of Attorney) reported the incident to someone and a report was filled out. He stated they (CNA's) "are dodging me now and haven't been taking my temperature. I think it has been worked out cause they wanted me to sign some paperwork yesterday but I didn't, my niece signed it." The resident stated he is usually very independent, but sometimes his [MEDICAL CONDITION] makes him too weak to toilet and clean himself afterwards and he has to ask for help. He stated this was not the first time some of the CNA's have given him "attitude" about helping him, telling him they know he can do it himself. Interview with the Risk Manager on 10/17/12 at 3:14 PM revealed she considers abuse to be "anything that affects the resident in a negative way whether it is physical or someone talking ugly to them". She denied having any incidents which she is required to report to state agencies, but then went on to state she has had issues with staff "having an attitude and being rough". She stated she is currently "gathering data" on two black CNA's that some residents are having "issues" with. She did not elaborate at this time but indicated she will be taking her findings to the administrator soon. During an interview with the Director of Nursing (DON) on 10/18/12 at 2:50 PM she stated she was not aware of any complaints of residents being treated roughly or rudely by staff. She acknowledged any such allegation should and would be reported to Adult Protective Services (APS). On 10/19/12 at 8:45 AM the DON approached this surveyor and stated she had been thinking about it all night since she was interviewed yesterday to try to figure out why we were asking the questions we asked. She stated she had information to present regarding resident #69. She stated the resident reported on 10/12/12 (a Friday) that a CNA treated him roughly when he asked for help to use the bathroom and clean himself after toileting. He reported he was told he could do it himself as he had always been independent. She stated neither she nor the Risk Manager were in the facility on that date and the Social Worker, Assistant Director of Nursing (ADON), and Administrator had addressed the problem with the resident and his representative. She said neither she nor the Risk Manager were aware of the situation until the following Monday, and they were told it had been resolved at that point. Resolution involved "team talk" during which CNA's were educated about [MEDICAL CONDITION] and the fact that a resident may be independent at times, but require considerable assistance at other times. She stated the resident's CNA assignment had also been changed and the employee he alleged was rough with him was no longer assigned to him. An interview with the Social Worker on 10/19/2012 at 9:27 AM confirmed she was aware of resident #69's allegations and that the resident and his POA had filed a grievance about this on 10/12/12. She stated the POA had called the facility on that date and reported the resident was "very upset with a situation that happened between him and a CNA". She stated the ADON had been notified and had spoken to the resident, but she, herself, did not speak to the resident until the following Tuesday. She stated she was not aware the resident had reported the CNA ran over his feet, or pushed him into the wall, only that he was handled "roughly and gruffly". An interview with the ADON on 10/19/2012 at 09:37 AM revealed she took a call on 10/12/12 from resident #69's POA letting her know she was coming to the facility and wanted to meet with the ADON about a complaint the resident had. She stated the POA told her the resident had complained that staff were not taking care of him and were refusing to help him to the bathroom. She stated "I was told that when he called for assistance to the bathroom, the CNA told him he could do it himself and he told her he could not". The ADON said she went to the residents room to investigate and was told by the resident that the CNA was rough with him and she examined the areas that he complained of. She stated "the resident told me the CNA roughly pushed him to the bathroom while in his wheelchair and was then roughly shoved back in the room. This surveyor questioned if resident #69 had complained of the CNA shoving him in his wheelchair into the wall and him hitting his head and if the resident complained of the CNA running over his feet. The ADON stated she was unclear about this but believed so and then commented that he got confused and changed his story, but he did say that when he was asked to move his feet he told her he couldn't because they were locked up and then the CNA ran over his feet. The ADON examined the residents feet and his side and there were no obvious injuries. She stated she immediately called a "team talk" and explained that all residents were to be treated with respect and dignity and if they ask for something or needed any assistance, staff were to assist the resident's with a smile on their face. She said she then took the CNA (CNA A) aside and told her she was disappointed and dissatisfied with her performance. The CNA's assignment was changed and she was told not to go into this residents room. When asked whether she reported the incident to APS she stated "I didn't report it because I thought it was resolved". She stated " His POA signed the grievance saying it was resolved but the resident did not sign it and the POA stated he was just wanting attention and he thought he could get some money out of this". Review of the grievance filed 10/12/12 by resident #69 and his POA revealed the following description of the incident. Resident #69 "called for assistance to use the restroom. CNA A told resident that he could go to the restroom by himself. When resident explained he could not she then proceeded to handle him in a rough manner when providing assistance. When he finished using the restroom she told him that he could clean himself. Resident unable to provide good hygiene for himself and feels that he is still dirty. Resident is expressing soreness to his right side and his feet (due to being unable to hold feet up during transport)." Actions/recommendations were listed as "Disciplinary action and education on resident's specific needs". Interview with resident #8 on 10/17/12 at 10:29 AM revealed his statement that "a couple of the girls here are rough when trying to sit down in the chair they would throw you down in the chair". He stated he has not reported this because he likes the girls and didn't want them to get into trouble. He stated one of the girls told him she was trying to get a job in law enforcement and one in corrections and he didn't want to ruin their future by having that on their record. Further interview with the resident on 10/19/12 at 10:30 AM revealed only the comment that some staff have been rough with him and "have an attitude". Review of Risk Manager investigation notes regarding allegations of possible abuse/inappropriate behavior by CNA C revealed documentation of an interview conducted with resident #23. The resident denied any problems with CNA C, but reported concerns with CNA's A and B. The notes quote the resident saying "those 2 black girls, they rough me around; call my tu-tu a cooter, put guilty feelings in my head. They tell me I should be grateful they clean me". The Risk Manager's notes also document interviews with unidentified staff who confirmed they have witnessed CNA's A and B being rude, using forceful handling of residents, and calling a resident "lazy and a fat ass". A documented interview with an unidentified nurse revealed residents receiving care by these two CNA's tend to have an increase in skin breakdown. Per these notes, all of these staff refused to give signed statements and requested they not be identified due to fear of job loss or retaliation by the CNA's, with one stating "there is no way I am going to cross those 2. No way." The notes state "Other staff members refuse to have their name attached to this investigation but indicated they also feel these CNA's are providing rough, rude and inadequate care to residents. They refuse to allow their names to be used in fear of reprisal from upper nurse management due to the well known close relationship both at work & outside of work". This evidence indicates multiple staff members have been made aware of intentional rudeness, refusal of care and services, and rough physical treatment of [REDACTED]. Staff did not report these incidents to appropriate state agencies for investigation and did not remove alleged perpetrators from the facility pending investigation, thereby placing all facility residents at risk for immediate jeopardy.

Based on resident and staff interview and record review, the facility failed to implement their policies and procedures to prohibit mistreatment, neglect and abuse for 3 of 60 facility residents (#8, 23 and 69). Multiple staff members had been made aware of intentional rudeness, refusal of care and services, and rough physical treatment of [REDACTED]. Staff did not report these incidents to appropriate state agencies, alleged perpetrators were not removed from the facility pending investigation, and the facility did not conduct a thorough investigation. The facility failure to implement their policies and procedures to identify, protect, investigate and report allegations of abuse led to a determination of Ongoing Immediate Jeopardy. The facility was informed of the finding of immediate Jeopardy on 10/19/12. The findings are: Interview with resident #69 on 10/17/2012 at 2:14 PM revealed an affirmative answer when he was asked if staff had ever been physically rough with him or rude to him. The resident stated he defines abuse as banging up on folks or not feeding them on time and or not feeding them at all, not helping them when they need help, or it could be seeing someone fall down and not helping them up. He stated that recently "I had my own experience with it. I have [MEDICAL CONDITION] and needed some help. When you need to go to the bathroom you need to go to the bathroom. I told two staff girls when I needed help with going to the bathroom. The CNA (Certified Nursing Assistant) told me I could do it myself. That girl pushed me in the wheelchair into the wall and then shoved me back into the wall and I hit the wall. One told me to move my feet but when you are locked in you are locked in and can't move. She ran over my feet." He stated he and his POA (Power of Attorney) reported the incident to someone and a report was filled out. He stated they (CNA's) "are dodging me now and haven't been taking my temperature. I think it has been worked out cause they wanted me to sign some paperwork yesterday but I didn't, my niece signed it." The resident stated he is usually very independent, but sometimes his [MEDICAL CONDITION] makes him too weak to toilet and clean himself afterwards and he has to ask for help. He stated this was not the first time some of the CNA's have given him "attitude" about helping him, telling him they know he can do it himself. Interview with the Risk Manager on 10/17/12 at 3:14 PM revealed she considers abuse to be "anything that affects the resident in a negative way whether it is physical or someone talking ugly to them". She denied having any incidents which she is required to report to state agencies, but then went on to state she has had issues with staff "having an attitude and being rough". She stated she is currently "gathering data" on two black CNA's that some residents are having "issues" with. She did not elaborate at this time but indicated she will be taking her findings to the administrator soon. She stated she'd had complaints about these CNA's from resident #23 who stated she didn't want them back in her room and if they came back in, she would hit them. The CNA's were not reassigned following this report to the Risk Manager, and the resident did hit one of the CNA's later on the same day when she entered the resident's room to provide care. During an interview with the Director of Nursing (DON) on 10/18/12 at 2:50 PM she stated she was not aware of any complaints of residents being treated roughly or rudely by staff. She acknowledged any such allegation should and would be reported to Adult Protective Services (APS). On 10/19/12 at 8:45 AM the DON approached this surveyor and stated she had been thinking about it all night since she was interviewed yesterday to try to figure out why we were asking the questions we asked. She stated she had information to present regarding resident #69. She stated the resident reported on 10/12/12 (a Friday) that a CNA treated him roughly when he asked for help to use the bathroom and clean himself after toileting. He reported he was told he could do it himself as he had always been independent. She stated neither she nor the Risk Manager were in the facility on that date and the Social Worker, Assistant Director of Nursing (ADON), and Administrator had addressed the problem with the resident and his representative. She said neither she nor the Risk Manager were aware of the situation until the following Monday, and they were told it had been resolved at that point. Resolution involved "team talk" during which CNA's were educated about [MEDICAL CONDITION] and the fact that a resident may be independent at times, but require considerable assistance at other times. She stated the resident's CNA assignment had also been changed and the employee he alleged was rough with him was no longer assigned to him. She acknowledged that this could be considered abuse and should have been reported to appropriate state agencies. She stated that not reporting was a violation of facility policies and procedures. An interview with the Social Worker on 10/19/2012 at 9:27 AM confirmed she was aware of resident #69's allegations and that the resident and his POA had filed a grievance about this on 10/12/12. She stated the POA had called the facility on that date and reported the resident was "very upset with a situation that happened between him and a CNA". She stated the ADON had been notified and had spoken to the resident, but she, herself, did not speak to the resident until the following Tuesday. She stated she was not aware the resident had reported the CNA ran over his feet, or pushed him into the wall, only that he was handled "roughly and gruffly". She confirmed she had not reported this grievance to any state agency for further investigation. An interview with the ADON on 10/19/2012 at 09:37 AM revealed she took a call on 10/12/12 from resident #69's POA letting her know she was coming to the facility and wanted to meet with the ADON about a complaint the resident had. She stated the POA told her the resident had complained that staff were not taking care of him and were refusing to help him to the bathroom. She stated "I was told that when he called for assistance to the bathroom, the CNA told him he could do it himself and he told her he could not". The ADON said she went to the residents room to investigate and was told by the resident that the CNA was rough with him and she examined the areas that he complained of. She stated "the resident told me the CNA roughly pushed him to the bathroom while in his wheelchair and was then roughly shoved back in the room. This surveyor questioned if resident #69 had complained of the CNA shoving him in his wheelchair into the wall and him hitting his head and if the resident complained of the CNA running over his feet. The ADON stated she was unclear about this but believed so and then commented that he got confused and changed his story, but he did say that when he was asked to move his feet he told her he couldn't because they were locked up and then the CNA ran over his feet. The ADON examined the residents feet and his side and there were no obvious injuries. She stated she immediately called a "team talk" and explained that all residents were to be treated with respect and dignity and if they ask for something or needed any assistance, staff were to assist the resident's with a smile on their face. She said she then took the CNA (CNA A) aside and told her she was disappointed and dissatisfied with her performance. The CNA's assignment was changed and she was told not to go into this residents room. The ADON was asked whether resident #69 is alert and oriented she stated "yes". She did not provide an explanation as to why further resident interview was not conducted if she was "unclear" about what the resident was reporting. She acknowledged she did not interview any other residents or staff related to this incident. When asked whether she reported the incident to APS she stated "I didn't report it because I thought it was resolved". She stated " His POA signed the grievance saying it was resolved but the resident did not sign it and the POA stated he was just wanting attention and he thought he could get some money out of this". Review of the grievance filed 10/12/12 by resident #69 and his POA revealed the following description of the incident. Resident #69 "called for assistance to use the restroom. CNA A told resident that he could go to the restroom by himself. When resident explained he could not she then proceeded to handle him in a rough manner when providing assistance. When he finished using the restroom she told him that he could clean himself. Resident unable to provide good hygiene for himself and feels that he is still dirty. Resident is expressing soreness to his right side and his feet (due to being unable to hold feet up during transport)." Actions/recommendations were listed as "Disciplinary action and education on resident's specific needs". Review of a psychiatric follow up note for resident #69 dated 10/18/12 revealed he reported having some issues with a CNA who did not want to help him when in the bathroom. Staff reported the resident saying a CNA "beat" him up and left bruises on both arms. No bruises were noted though. This note documents that staff were aware of resident complaints of physical abuse/mistreatment. There is no documentation than any staff member receiving this report form the resident reported the incident to appropriate state agencies for investigation. Interview with resident #8 on 10/17/12 at 10:29 AM revealed his statement that "a couple of the girls here are rough when trying to sit down in the chair they would throw you down in the chair". He stated he has not reported this because he likes the girls and didn't want them to get into trouble. He stated one of the girls told him she was trying to get a job in law enforcement and one in corrections and he didn't want to ruin their future by having that on their record. Further interview with the resident on 10/19/12 at 10:30 AM revealed only the comment that some staff have been rough with him and "have an attitude". Review of Risk Manager investigation notes regarding allegations of possible abuse/inappropriate behavior by CNA C revealed documentation of an interview conducted with resident #23. The resident denied any problems with CNA C, but reported concerns with CNA's A and B. The notes quote the resident saying "those 2 black girls, they rough me around; call my tu-tu a cooter, put guilty feelings in my head. They tell me I should be grateful they clean me". The Risk Manager's notes also document interviews with unidentified staff who confirmed they have witnessed CNA's A and B being rude, using forceful handling of residents, and calling a resident "lazy and a fat ass". A documented interview with an unidentified nurse revealed residents receiving care by these two CNA's tend to have an increase in skin breakdown. Per these notes, all of these staff refused to give signed statements and requested they not be identified due to fear of job loss or retaliation by the CNA's, with one stating "there is no way I am going to cross those 2. No way." The notes state "Other staff members refuse to have their name attached to this investigation but indicated they also feel these CNA's are providing rough, rude and inadequate care to residents. They refuse to allow their names to be used in fear of reprisal from upper nurse management due to the well known close relationship both @ work & outside of work". Review of the facility abuse policy revealed a definition of neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". The policy stated all facility staff will be trained to recognize and report abuse/neglect and that "Anyone who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion". It stated that prevention of abuse will be accomplished by timely reporting of any suspected abuse and a thorough investigation of these instances. The section on investigation of abuse stated any incidents of suspected abuse will be investigated with a report filed to appropriate governing agencies. The policy stated any staff member alleged or suspected of abuse should be suspended pending a full investigation and conclusion to the investigation. The associate should not have any contact with the alleged victim until the case is fully resolved. Upon suspicion of abuse, the Administrator, DON, Florida Abuse hotline, and Risk Manager are to be notified. Interview and record review revealed that numerous staff members were aware of allegations of both physical and verbal abuse/mistreatment of [REDACTED]. Residents were not protected from further abuse as alleged perpetrators were not suspended pending investigation of allegations. Allegations made by resident #69 were not thoroughly investigated.

Based on resident and staff interview and record review, the facility failed to implement their policies and procedures to prohibit mistreatment, neglect and abuse of residents for 3 of 60 facility residents (#8, 23 and 69). Multiple staff members had been made aware of intentional rudeness, refusal of care and services, and rough physical treatment of [REDACTED]. Staff did not report these incidents to appropriate state agencies, alleged perpetrators were not removed from the facility pending investigation, and the facility did not conduct a thorough investigation. The facility failure to implement their policies and procedures to identify, protect, investigate and report allegations of abuse led to a determination of Ongoing Immediate Jeopardy. The facility was informed of the finding of immediate Jeopardy on 10/19/12. The findings are: Interview with resident #69 on 10/17/2012 at 2:14 PM revealed an affirmative answer when he was asked if staff had ever been physically rough with him or rude to him. The resident stated he defines abuse as banging up on folks or not feeding them on time and or not feeding them at all, not helping them when they need help, or it could be seeing someone fall down and not helping them up. He stated that recently "I had my own experience with it. I have [MEDICAL CONDITION] and needed some help. When you need to go to the bathroom you need to go to the bathroom. I told two staff girls when I needed help with going to the bathroom. The CNA (Certified Nursing Assistant) told me I could do it myself. That girl pushed me in the wheelchair into the wall and then shoved me back into the wall and I hit the wall. One told me to move my feet but when you are locked in you are locked in and can't move. She ran over my feet." He stated he and his POA (Power of Attorney) reported the incident to someone and a report was filled out. He stated they (CNA's) "are dodging me now and haven't been taking my temperature. I think it has been worked out cause they wanted me to sign some paperwork yesterday but I didn't, my niece signed it." The resident stated he is usually very independent, but sometimes his [MEDICAL CONDITION] makes him too weak to toilet and clean himself afterwards and he has to ask for help. He stated this was not the first time some of the CNA's have given him "attitude" about helping him, telling him they know he can do it himself. Interview with the Risk Manager on 10/17/12 at 3:14 PM revealed she considers abuse to be "anything that affects the resident in a negative way whether it is physical or someone talking ugly to them". She denied having any incidents which she is required to report to state agencies, but then went on to state she has had issues with staff "having an attitude and being rough". She stated she is currently "gathering data" on two black CNA's that some residents are having "issues" with. She did not elaborate at this time but indicated she will be taking her findings to the administrator soon. She stated she'd had complaints about these CNA's from resident #23 who stated she didn't want them back in her room and if they came back in, she would hit them. The CNA's were not reassigned following this report to the Risk Manager, and the resident did hit one of the CNA's later on the same day when she entered the resident's room to provide care. During an interview with the Director of Nursing (DON) on 10/18/12 at 2:50 PM she stated she was not aware of any complaints of residents being treated roughly or rudely by staff. She acknowledged any such allegation should and would be reported to Adult Protective Services (APS). On 10/19/12 at 8:45 AM the DON approached this surveyor and stated she had been thinking about it all night since she was interviewed yesterday to try to figure out why we were asking the questions we asked. She stated she had information to present regarding resident #69. She stated the resident reported on 10/12/12 (a Friday) that a CNA treated him roughly when he asked for help to use the bathroom and clean himself after toileting. He reported he was told he could do it himself as he had always been independent. She stated neither she nor the Risk Manager were in the facility on that date and the Social Worker, Assistant Director of Nursing (ADON), and Administrator had addressed the problem with the resident and his representative. She said neither she nor the Risk Manager were aware of the situation until the following Monday, and they were told it had been resolved at that point. Resolution involved "team talk" during which CNA's were educated about [MEDICAL CONDITION] and the fact that a resident may be independent at times, but require considerable assistance at other times. She stated the resident's CNA assignment had also been changed and the employee he alleged was rough with him was no longer assigned to him. She acknowledged that this could be considered abuse and should have been reported to appropriate state agencies. She stated that not reporting was a violation of facility policies and procedures. An interview with the Social Worker on 10/19/2012 at 9:27 AM confirmed she was aware of resident #69's allegations and that the resident and his POA had filed a grievance about this on 10/12/12. She stated the POA had called the facility on that date and reported the resident was "very upset with a situation that happened between him and a CNA". She stated the ADON had been notified and had spoken to the resident, but she, herself, did not speak to the resident until the following Tuesday. She stated she was not aware the resident had reported the CNA ran over his feet, or pushed him into the wall, only that he was handled "roughly and gruffly". She confirmed she had not reported this grievance to any state agency for further investigation. An interview with the ADON on 10/19/2012 at 09:37 AM revealed she took a call on 10/12/12 from resident #69's POA letting her know she was coming to the facility and wanted to meet with the ADON about a complaint the resident had. She stated the POA told her the resident had complained that staff were not taking care of him and were refusing to help him to the bathroom. She stated "I was told that when he called for assistance to the bathroom, the CNA told him he could do it himself and he told her he could not". The ADON said she went to the residents room to investigate and was told by the resident that the CNA was rough with him and she examined the areas that he complained of. She stated "the resident told me the CNA roughly pushed him to the bathroom while in his wheelchair and was then roughly shoved back in the room. This surveyor questioned if resident #69 had complained of the CNA shoving him in his wheelchair into the wall and him hitting his head and if the resident complained of the CNA running over his feet. The ADON stated she was unclear about this but believed so and then commented that he got confused and changed his story, but he did say that when he was asked to move his feet he told her he couldn't because they were locked up and then the CNA ran over his feet. The ADON examined the residents feet and his side and there were no obvious injuries. She stated she immediately called a "team talk" and explained that all residents were to be treated with respect and dignity and if they ask for something or needed any assistance, staff were to assist the resident's with a smile on their face. She said she then took the CNA (CNA A) aside and told her she was disappointed and dissatisfied with her performance. The CNA's assignment was changed and she was told not to go into this residents room. The ADON was asked whether resident #69 is alert and oriented she stated "yes". She did not provide an explanation as to why further resident interview was not conducted if she was "unclear" about what the resident was reporting. She acknowledged she did not interview any other residents or staff related to this incident. When asked whether she reported the incident to APS she stated " I didn't report it because I thought it was resolved". She stated " His POA signed the grievance saying it was resolved but the resident did not sign it and the POA stated he was just wanting attention and he thought he could get some money out of this". Review of the grievance filed 10/12/12 by resident #69 and his POA revealed the following description of the incident. Resident #69 "called for assistance to use the restroom. CNA A told resident that he could go to the restroom by himself. When resident explained he could not she then proceeded to handle him in a rough manner when providing assistance. When he finished using the restroom she told him that he could clean himself. Resident unable to provide good hygiene for himself and feels that he is still dirty. Resident is expressing soreness to his right side and his feet (due to being unable to hold feet up during transport)." Actions/recommendations were listed as "Disciplinary action and education on resident's specific needs". Review of a psychiatric follow up note for resident #69 dated 10/18/12 revealed he reported having some issues with a CNA who did not want to help him when in the bathroom. Staff reported the resident saying a CNA "beat" him up and left bruises on both arms. No bruises were noted though. This note documents that staff were aware of resident complaints of physical abuse/mistreatment. There is no documentation than any staff member receiving this report form the resident reported the incident to appropriate state agencies for investigation. Interview with resident #8 on 10/17/12 at 10:29 AM revealed his statement that "a couple of the girls here are rough when trying to sit down in the chair they would throw you down in the chair". He stated he has not reported this because he likes the girls and didn't want them to get into trouble. He stated one of the girls told him she was trying to get a job in law enforcement and one in corrections and he didn't want to ruin their future by having that on their record. Further interview with the resident on 10/19/12 at 10:30 AM revealed only the comment that some staff have been rough with him and "have an attitude". Review of Risk Manager investigation notes regarding allegations of possible abuse/inappropriate behavior by CNA C revealed documentation of an interview conducted with resident #23. The resident denied any problems with CNA C, but reported concerns with CNA's A and B. The notes quote the resident saying "those 2 black girls, they rough me around; call my tu-tu a cooter, put guilty feelings in my head. They tell me I should be grateful they clean me". The Risk Manager's notes also document interviews with unidentified staff who confirmed they have witnessed CNA's A and B being rude, using forceful handling of residents, and calling a resident "lazy and a fat ass". A documented interview with an unidentified nurse revealed residents receiving care by these two CNA's tend to have an increase in skin breakdown. Per these notes, all of these staff refused to give signed statements and requested they not be identified due to fear of job loss or retaliation by the CNA's, with one stating "there is no way I am going to cross those 2. No way." The notes state "Other staff members refuse to have their name attached to this investigation but indicated they also feel these CNA's are providing rough, rude and inadequate care to residents. They refuse to allow their names to be used in fear of reprisal from upper nurse management due to the well known close relationship both @ work & outside of work". Review of the facility abuse policy revealed a definition of neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". The policy states all facility staff will be trained to recognize and report abuse/neglect and that "Anyone who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion". It states that prevention of abuse will be accomplished by timely reporting of any suspected abuse and a thorough investigation of these instances. The section on investigation of abuse states any incidents of suspected abuse will be investigated with a report filed to appropriate governing agencies. The policy states any staff member alleged or suspected of abuse should be suspended pending a full investigation and conclusion to the investigation. The associate should not have any contact with the alleged victim until the case is fully resolved. Upon suspicion of abuse, the Administrator, DON, Florida Abuse hotline, and Risk Manager are to be notified. Interview and record review revealed that numerous staff members were aware of allegations of both physical and verbal abuse/mistreatment of [REDACTED]. Residents were not protected from further abuse as alleged perpetrators were not suspended pending investigation of allegations. Allegations made by resident #69 were not thoroughly investigated.

Based on resident interview, staff interview and record review, the administrator failed to ensure abuse policies were implemented. It was determined the facility was not administered in a manner to prevent resident mistreatment and abuse which resulted in Immediate Jeopardy for 3 of 60 facility residents (#8, 23, and 69). The facility failure to implement their abuse policies to identify, report, protect, and thoroughly investigate allegations of abuse led to a determination of Ongoing Immediate Jeopardy. The facility was informed of the finding of immediate Jeopardy on 10/19/12. The findings are: Interview with the administrator on 10/19/12 at 3:15 pm stated these allegations were brought to his attention concerning him about a grievance. "It was brought to my attention on 10/12/12 for resident #69 of a grievance related to care not possible abuse. On Monday 10/15/12, I was notified that the resident alleged physical abuse by CNA (Certified Nursing Assistant) and we considered this as a grievance. We did not call to report alleged abuse." Review of the grievance filed 10/12/12 by resident #69 and his POA (Power of Attorney) revealed the following description of the incident. Resident #69 "called for assistance to use the restroom. CNA A told resident that he could go to the restroom by himself. When resident explained he could not she then proceeded to handle him in a rough manner when providing assistance. When he finished using the restroom she told him that he could clean himself. Resident unable to provide good hygiene for himself and feels that he is still dirty. Resident is expressing soreness to his right side and his feet (due to being unable to hold feet up during transport)." Further interview indicated the administrator was informed on Monday 10/15/12 of alleged verbal abuse for resident # 23 at which time he suspended the CNA involved pending completion of the investigation. He stated "We did not call to report alleged abuse." Additional interview with the administrator stated on Thursday 10/18/12 3:20 PM "it was brought to my attention of ongoing investigation by the risk manager concerning allegations of verbal and physical abuse regarding two CNA's. We did not call to report alleged abuse". Refer to F223 - Facility failure to ensure residents are free of verbal/physical abuse. Refer to F224 - Facility failure to implement abuse policies and procedures. Refer to F225 - Facility failure to ensure that allegations of abuse were reported to appropriate state agencies. Refer to F226 - Facility failure to ensure allegations of abuse were reported; failure to thoroughly investigate allegations of abuse; failure to protect residents from further potential abuse.

Based on staff and resident interview and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to appropriate state agencies, including Adult Protective Services (APS) and the Agency for Health Care Administration (AHCA). The facility failed to thoroughly investigate such allegations, and failed to protect residents from further potential abuse while the investigation was in progress. The facility failure to report, protect, and thoroughly investigate allegations of abuse led to a determination of Ongoing Immediate Jeopardy. The facility was informed of the finding of Immediate Jeopardy on 10/19/12. The findings are: Interview with resident #69 on 10/17/2012 at 2:14 PM revealed an affirmative answer when he was asked if staff had ever been physically rough with him or rude to him. The resident stated he defines abuse as banging up on folks or not feeding them on time and or not feeding them at all, not helping them when they need help, or it could be seeing someone fall down and not helping them up. He stated that recently "I had my own experience with it. I have [MEDICAL CONDITION] and needed some help. When you need to go to the bathroom you need to go to the bathroom. I told two staff girls when I needed help with going to the bathroom. The CNA (Certified Nursing Assistant) told me I could do it myself. That girl pushed me in the wheelchair into the wall and then shoved me back into the wall and I hit the wall. One told me to move my feet but when you are locked in you are locked in and can't move. She ran over my feet." He stated he and his POA (Power of Attorney) reported the incident to someone and a report was filled out. He stated they (CNA's) "are dodging me now and haven't been taking my temperature. I think it has been worked out cause they wanted me to sign some paperwork yesterday but I didn't, my niece signed it." The resident stated he is usually very independent, but sometimes his [MEDICAL CONDITION] makes him too weak to toilet and clean himself afterwards and he has to ask for help. He stated this was not the first time some of the CNA's have given him "attitude" about helping him, telling him they know he can do it himself. Interview with the Risk Manager on 10/17/12 at 3:14 PM revealed she considers abuse to be "anything that affects the resident in a negative way whether it is physical or someone talking ugly to them". She denied having any incidents which she is required to report to state agencies, but then went on to state she has had issues with staff "having an attitude and being rough". She stated she is currently "gathering data" on two black CNA's that some residents are having "issues" with. She did not elaborate at this time but indicated she will be taking her findings to the administrator soon. She stated she'd had complaints about these CNA's from resident #23 who stated she didn't want them back in her room and if they came back in, she would hit them. The CNA's were not reassigned following this report to the Risk Manager, and the resident did hit one of the CNA's later on the same day when she entered the resident's room to provide care. During an interview with the Director of Nursing (DON) on 10/18/12 at 2:50 PM she stated she was not aware of any complaints of residents being treated roughly or rudely by staff. She acknowledged any such allegation should and would be reported to Adult Protective Services (APS). On 10/19/12 at 8:45 AM the DON approached this surveyor and stated she had been thinking about it all night since she was interviewed yesterday to try to figure out why we were asking the questions we asked. She stated she had information to present regarding resident #69. She stated the resident reported on 10/12/12 (a Friday) that a CNA treated him roughly when he asked for help to use the bathroom and clean himself after toileting. He reported he was told he could do it himself as he had always been independent. She stated neither she nor the Risk Manager were in the facility on that date and the Social Worker, Assistant Director of Nursing (ADON), and Administrator had addressed the problem with the resident and his representative. She said neither she nor the Risk Manager were aware of the situation until the following Monday, and they were told it had been resolved at that point. Resolution involved "team talk" during which CNA's were educated about [MEDICAL CONDITION] and the fact that a resident may be independent at times, but require considerable assistance at other times. She stated the resident's CNA assignment had also been changed and the employee he alleged was rough with him was no longer assigned to him. She acknowledged that this could be considered abuse and should have been reported to appropriate state agencies. She stated that not reporting was a violation of facility policies and procedures. An interview with the Social Worker on 10/19/2012 at 9:27 AM confirmed she was aware of resident #69's allegations and that the resident and his POA had filed a grievance about this on 10/12/12. She stated the POA had called the facility on that date and reported the resident was "very upset with a situation that happened between him and a CNA". She stated the ADON had been notified and had spoken to the resident, but she, herself, did not speak to the resident until the following Tuesday. She stated she was not aware the resident had reported the CNA ran over his feet, or pushed him into the wall, only that he was handled "roughly and gruffly". She confirmed she had not reported this grievance to any state agency for further investigation. An interview with the ADON on 10/19/2012 at 09:37 AM revealed she took a call on 10/12/12 from resident #69's POA letting her know she was coming to the facility and wanted to meet with the ADON about a complaint the resident had. She stated the POA told her the resident had complained that staff were not taking care of him and were refusing to help him to the bathroom. She stated "I was told that when he called for assistance to the bathroom, the CNA told him he could do it himself and he told her he could not". The ADON said she went to the residents room to investigate and was told by the resident that the CNA was rough with him and she examined the areas that he complained of. She stated "the resident told me the CNA roughly pushed him to the bathroom while in his wheelchair and was then roughly shoved back in the room. This surveyor questioned if resident #69 had complained of the CNA shoving him in his wheelchair into the wall and him hitting his head and if the resident complained of the CNA running over his feet. The ADON stated she was unclear about this but believed so and then commented that he got confused and changed his story, but he did say that when he was asked to move his feet he told her he couldn't because they were locked up and then the CNA ran over his feet. The ADON examined the residents feet and his side and there were no obvious injuries. She stated she immediately called a "team talk" and explained that all residents were to be treated with respect and dignity and if they ask for something or needed any assistance, staff were to assist the resident's with a smile on their face. She said she then took the CNA (CNA A) aside and told her she was disappointed and dissatisfied with her performance. The CNA's assignment was changed and she was told not to go into this residents room. The ADON was asked whether resident #69 is alert and oriented she stated "yes". She did not provide an explanation as to why further resident interview was not conducted if she was "unclear" about what the resident was reporting. She acknowledged she did not interview any other residents or staff related to this incident. When asked whether she reported the incident to APS she stated " I didn't report it because I thought it was resolved". She stated " His POA signed the grievance saying it was resolved but the resident did not sign it and the POA stated he was just wanting attention and he thought he could get some money out of this". Review of the grievance filed 10/12/12 by resident #69 and his POA revealed the following description of the incident. Resident #69 "called for assistance to use the restroom. CNA A told resident that he could go to the restroom by himself. When resident explained he could not she then proceeded to handle him in a rough manner when providing assistance. When he finished using the restroom she told him that he could clean himself. Resident unable to provide good hygiene for himself and feels that he is still dirty. Resident is expressing soreness to his right side and his feet (due to being unable to hold feet up during transport)." Actions/recommendations were listed as "Disciplinary action and education on resident's specific needs". Review of a psychiatric follow up note for resident #69 dated 10/18/12 revealed he reported having some issues with a CNA who did not want to help him when in the bathroom. Staff reported the resident saying a CNA "beat" him up and left bruises on both arms. No bruises were noted though. This note documents that staff were aware of resident complaints of physical abuse/mistreatment. There is no documentation than any staff member receiving this report form the resident reported the incident to appropriate state agencies for investigation. Interview with resident #8 on 10/17/12 at 10:29 AM revealed his statement that "a couple of the girls here are rough when trying to sit down in the chair they would throw you down in the chair". He stated he has not reported this because he likes the girls and didn't want them to get into trouble. He stated one of the girls told him she was trying to get a job in law enforcement and one in corrections and he didn't want to ruin their future by having that on their record. Further interview with the resident on 10/19/12 at 10:30 AM revealed only the comment that some staff have been rough with him and "have an attitude". Review of Risk Manager investigation notes regarding allegations of possible abuse/inappropriate behavior by CNA C revealed documentation of an interview conducted with resident #23. The resident denied any problems with CNA C, but reported concerns with CNA's A and B. The notes quote the resident saying "those 2 black girls, they rough me around; call my tu-tu a cooter, put guilty feelings in my head. They tell me I should be grateful they clean me". The Risk Manager's notes also document interviews with unidentified staff who confirmed they have witnessed CNA's A and B being rude, using forceful handling of residents, and calling a resident "lazy and a fat ass". A documented interview with an unidentified nurse revealed residents receiving care by these two CNA's tend to have an increase in skin breakdown. Per these notes, all of these staff refused to give signed statements and requested they not be identified due to fear of job loss or retaliation by the CNA's, with one stating "there is no way I am going to cross those 2. No way." The notes state "Other staff members refuse to have their name attached to this investigation but indicated they also feel these CNA's are providing rough, rude and inadequate care to residents. They refuse to allow their names to be used in fear of reprisal from upper nurse management due to the well known close relationship both @ work & outside of work". Review of the facility abuse policy revealed a definition of neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". The policy states all facility staff will be trained to recognize and report abuse/neglect and that "Anyone who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion". It states that prevention of abuse will be accomplished by timely reporting of any suspected abuse and a thorough investigation of these instances. The section on investigation of abuse states any incidents of suspected abuse will be investigated with a report filed to appropriate governing agencies. The policy states any staff member alleged or suspected of abuse should be suspended pending a full investigation and conclusion to the investigation. The associate should not have any contact with the alleged victim until the case is fully resolved. Upon suspicion of abuse, the Administrator, DON, Florida Abuse hotline, and Risk Manager are to be notified. Interview and record review revealed that numerous staff members were aware of allegations of both physical and verbal abuse/mistreatment of [REDACTED]. Residents were not protected from further abuse as alleged perpetrators were not suspended pending investigation of allegations. CNA A and B were not suspended from duty until state surveyors determined immediate jeopardy at the facility on 10/19/12. Allegations made by resident #69 were not thoroughly investigated.