Every finding on record at Southfield Village

Based on observation and interview the facility failed to provide a clean and sanitary environment for food preparation and failed to ensure meals served to Resident 11 were within safe serving temperatures. This had the potential to affect 57 of 57 residents who consumed food prepared in the kitchen. Finding includes: 1. During a tour and observation of the kitchen on 1/7/2026 at 9:51 A.M. the following issues were noted: -3 fans in the food preparation area were dusty. -the walls, ceiling, and light fixtures were dusty. -the wall behind the stove and griddle had yellowish-brown matter on it. During an interview on 1/7/2025 at 10:05 A.M., the Dietary Manager indicated there should not be dust on the fans, walls, ceiling, and light fixtures, and the wall behind the griddle should have been clean. On 1/12/2026 at 10:04 A.M. the Dietary Manager indicated there was not a policy for cleaning the kitchen but provided the cleaning schedule that staff followed. 2. During an observation on 1/9/2026 at 9:30 A.M., Resident 11's breakfast tray had been placed on a table in the common area of the 100 Hall. Resident 11 was still sleeping. During an interview on 1/9/2026 at 10:04 A.M., CNA 7 indicated she had taken the tray from the table and heated Resident 11's food in the microwave. CNA 7 indicated Resident 11 was having an omelette, a danish and a cup of coffee. CNA 7 had not taken the temperature of any of the food after she microwaved it and before she gave Resident 11 his tray. CNA 7 indicated the breakfast trays had arrived at 7:40 A.M. During an observation on 1/12/2025 7:50 A.M., 100 Hall breakfast trays arrived to the unit. Resident 11 was still sleeping. During an observation on 1/12/2025 at 9:04 A.M., CNA 7 gave Resident 11 his breakfast tray. Resident 11 was having a omelette and a cup of coffee. During an interview on 1/12/2025 at 9:05 A.M., CNA 7 indicated Resident 11's breakfast tray had been heated in the microwave and had not had the food's temperature taken before giving the food to the resident. During a follow-up interview on 1/12/2025 at 9:07 A.M., CNA 7 indicated she had misspoke and the breakfast tray she had just delivered to Resident 11 had been a new tray the kitchen had just made. During an interview on 1/12/2025 at 9:08 A.M., the Director of Dining (DOD) indicated the kitchen had not remade Resident 11's breakfast tray. The DOD indicated he did not know how long high-risk food could remain out before it would have needed to be remade. The DOD indicated the nursing staff should have taken the temperature of the omelette after it had been reheated. During an interview on 1/13/2025 at 10:15 A.M., the DOD indicated high-risk foods such as eggs could safely sit out for four hours before the food needed to be refrigerated or discarded. On 1/12/2025 at 9:47 A.M., the Executive Director provided a policy, dated 10/28/2025 and titled, Food Safety Requirements, and identified it as the policy currently used by the facility. The policy indicated, . a. Reheating . i. Foods reheated in a microwave oven must be reheated so that all parts of the food reach a temperature of at least 165 F The Federal Department of Agriculture 2022 Food Code was retrieved on 1/14/2025 from the FDA's website at https://www.fda.gov/media/164194/download?attachment. The guidance indicated food should be placed into the refrigerator 2 hours after it is removed from its holding temperature to avoid the growth of harmful bacteria. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to keep medication and treatment carts secured on 3 of 3 halls. (100, 200 and 300 Halls)Findings include: 1. During an observation of the medication cart, on the 100 Hall, on 1/9/2026 from 8:52 A.M. until 8:57 A.M., the medication cart had been unlocked and unattended. During an interview on 1/9/2026 at 8:57 A.M., Registered Nurse 5 indicated the medication cart was not locked, but should have been locked. 2. During an observation of the medication cart, on the 300 Hall, on 1/9/2026 from 8:58 A.M. until 9:03 A.M., the medication cart was unlocked and unattended. During an interview on 1/9/2026 at 9:03 A.M., RN 6 indicated she had been responsible for the medication cart and the medication cart was not locked while she had been in a resident's room and was unable to visualize the cart from the room. 3. During an observation of the treatment cart, on the 300 Hall, on 1/9/2026 from 9:05 A.M. until 9:07 A.M., the cart had been unlocked and was unattended. The treatment cart contained prescribed topical creams and gels, antifungal cream and antifungal powder for residents. During an interview on 1/9/2025 at 9:07 A.M., RN 6 indicated the treatment cart had not been locked, but should have been locked. 4. During an observation of the medication cart on the 200 Hall on 1/11/2026 at 4:25 P.M., the medication cart was unlocked and unattended. During an interview on 1/11/2026 at 4:26 P.M., LPN 3 indicated the medication cart had not been locked but should have been locked. 5. During an observation of the treatment cart on the 200 Hall on 1/11/2026 from 4:29 P.M. until 5:50 P.M., the treatment cart was unlocked and unattended. The treatment cart contained prescribed topical creams and gels, antifungal cream and antifungal powder for residents. During an interview on 1/11/2026 at 5:50 P.M., the Executive Director indicated the treatment cart should not have been left unlocked. On 1/9/2025 at 1:59 P.M., the Director of Nursing (DON) provided a policy dated, 4/9/2019 and titled, Medication Storage Policy. The DON indicated it was the policy currently being used by the facility. The policy indicated, . 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments (i.e., medications carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls 3.1-25 (m)

Based on interview, observation and record review, the facility failed to provide meals at a palatable temperature for the 100 Hall meal trays. This had the potential to affect 18 of 18 residents who received their meals in their rooms or on the 100 Hall common area. Finding includes: During an interview on 1/7/2025 at 11:18 A.M., Resident 11 indicated he ate all of his meals in his room and most of his meals were served to him cold. Resident 11 indicated he was able to ask for the meal to be reheated but then he had to wait to eat and it was every meal. During an interview on 1/7/2025 at 11:50 A.M., Resident 6 indicated she ate her meals in the common area of the 100 Hall. She indicated most of her meals had been served lukewarm or cold and she had stopped requesting her food to be reheated. During an observation of the 100 Hall lunch meal service on 1/12/2025. The meal cart arrived at 12:02 P.M. and at 12:15 P.M., Directory of Dietary (DOD) had taken the temperature of the grilled cheese sandwich on the last meal tray for the 100 Hall. The grilled cheeses' temperature was 107 Fahrenheit (F). During an interview with the DOD on 1/12/2025 at 12:20 P.M., the DOD indicated he was not sure what the temperature of the grilled cheese should have been when it was served. The DOD indicated the hold temperature for hot food was 135 F. The Executive Director (ED) provided a policy dated, 11/28/2025 and titled, Food Safety Requirements. The ED indicated the policy was the one currently used by the facility. The policy indicated, . 4. When preparing food, team members should take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards . d. Holding - Maintain proper hot and cold holding temperatures. Team members should refer to the current FDA Food Code and community policy for foor temperatures as needed. The Federal Department of Agriculture 2022 Food Code was retrieved on 1/14/2025 from the FDA's website at https://www.fda.gov/media/164194/download?attachment. The guidance indicated food should be held and served at 135 F to avoid the growth of harmful bacteria. 3.1-21(a)(2)

Based on observation, interview and record review, the facility failed to follow infection prevention practices during wound care, Foley (indwelling urinary catheter) care and failed to keep a urinary drainage bag off the floor during for 1 of 3 residents observed for infection control. (Resident 6)Findings include: 1. During an observation on 1/9/2026 at 2:30 P.M., Resident 6's door to her room had a sign indicating the resident was in Enhanced Barrier Precautions (EBP) and staff should wear a gown, gloves and mask anytime staff was providing care related to the resident's indwelling catheter. CNA 2 was observed emptying the foley urinary drainage bag without wearing Personal Protective Equipment (PPE). During an interview on 1/9/2025 at 2:34 P.M., CNA 2 indicated she did not believe she needed to wear the PPE while emptying Resident 6's urinary drainage bag. During a follow-up interview on 1/9/2025 at 2:36 P.M., CNA 2 indicated PPE should have been worn while emptying Resident 6's urinary catheter bag. Resident 6's record review was completed on 1/11/2026 at 5:15 P.M. Diagnoses included, but were not limited to: spinal stenosis, anemia, unstageable pressure ulcer on buttocks and fractured vertebrae. A current Physician's order, initiated on 10/6/2025, indicated Resident 6 was to be in Enhanced Barrier Precautions. Staff were wear gloves and gowns when providing high risk activities (dressing, bathing, showering, transferring, changing linens, providing hygiene, changing or assisting with toileting, device care and wound care) related to Foley catheter and surgical/pressure wounds. A current Care Plan, initiated on 8/20/2025 indicated Resident 6 required EBPs related to pressure injuries and foley catheter. An intervention to the Care Plan, initiated on 8/20/2025 indicated as part of standard precautions, additional PPE may be required. 2. During an observation on 1/12/2026 at 8:40 A.M., Resident 6 was seated in the common area of the 100 Hall eating breakfast. The urinary drainage bag was laying on the ground under the resident's chair. During an interview on 1/12/2026 at 9:00 A.M., RN 5 indicated the urinary drainage bag should not have been on the floor. During an interview on 1/12/2026 at 10:00 A.M., the Director of Nursing (DON) indicated the facility did not have a policy regarding urinary drainage bags, but the facility followed the Standards of Care. 3. During an observation of Resident 6's wound care on 1/12/2026 at 11:06 A.M., the Wound Nurse/Infection Preventionist Nurse (WN/IPN) removed a dressing from Resident 6's right buttocks, removed the packing from the wound and took the protective dressing off the resident's coccyx (a small triangular bone at the base of the spinal column) . The WN/IPN inserted her index finger into the wound on the buttocks to assess the direction of wound channeling, measured the wound with a cotton swab, cleaned the wound with sterile saline solution, used a medicated pad around the wound's edges, applied medicated ointment, packed the wound with a medicated packing material and covered both the buttocks wound and the coccyx with clean bandages. Next, the WN/IPN turned the resident onto her back and provided urinary catheter care by cleaning the catheter with soap and water. The WN/IPN's gloves were not changed or hand sanitizer used after removing the dirty dressings, before applying the treatments, before applying the new bandages, nor before providing urinary catheter care. After the WN/IPN provided the resident with urinary catheter care, the WN/IPN used hand sanitizer and put on clean gloves. She then proceeded to remove a border gauze dressing from the resident's thigh wounds. She then cleansed the wounds with sterile saline, followed by wiping a medicated pad on both wounds. The WN/IPN used the same medicated pad to wipe both wounds and the same cotton swab to measure both wounds and then applied a border gauze dressing to the wounds on the residents' left and right thigh. The WN/IPN gloves were not changed after she removed the old bandages nor before treating, measuring or covering either thigh wound. Next, the WN/IPN removed band aides from the resident's second and third toes. The WN/IPN did not change her gloves or use hand sanitizer after removing the bandaids and before cleaning the 4th toe, measuring the wound or putting a clean bandage on the toe. Finally, the WN/IPN removed the dressing from Resident 6's left heal, measured the heal, used sterile saline to clean the heel, wipes a medicated pad, around the wound's edges, applied a collagen treatment to the wound, covered the wound with a clean bandage and then placed the resident's sock back on her foot. The WN/IPN did not use hand sanitizer or change her gloves after removing the dressing, before starting the treatment or before applying a clean bandage. During an interview on 1/12/2026 at 11:40 A.M., the WN/IPN indicated she had been changing dressings for over 20 years and did not needed to change her gloves or use hand sanitizer after removing dirty dressings, after applying treatments or before applying a clean bandage. The WN/IPN indicated she should have changed her gloves and used hand sanitizer before starting urinary catheter care. During an interview on 1/12/2026 at 11:45 A.M., the Director of Nursing (DON) indicated during wound care, gloves should be changed and hand sanitizer used after removing a dirty dressing, after completing the wound treatment and before applying a clean bandage. On 1/12/2025 at 10:46 A.M., the DON provided a policy, dated 6/12/2025 and titled, Enhanced Barrier Precautions, and identified the policy as the one currently used by the facility. The policy indicated, . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds, indwelling medical devices (e.g., central lines, urinary catheters, ventilator tubes/tracheostomy, hemodialysis catheters and PICC lines) even if the resident is not known to be infected or colonized by MDRO On 1/12/2025 at 1:46 P.M., the DON provided a policy, dated 1/29/2024 and titled, Catheter Care Policy, and identified the policy as the one currently used by the facility. The policy indicated, . Implementation Guidelines: . 7. perform hand hygiene 8. don gloves On 1/12/2025 at 10:46 A.M., the DON provided a policy, dated 7/16/2025 and titled, Wound Treatment Policy, and identified the policy as the one currently used by the facility. The policy indicated, . 2. All wound care shall be performed using appropriate infection control practices and per community guidelines 3.1-18(a)

Based on interview and record review, the facility failed to follow physician orders and notify the physician of elevated blood pressures for 1 of 5 residents reviewed for unnecessary medications. (Resident 2)Finding includes: A record review was completed on 1/9/2026 at 12:19 P.M. Diagnoses included, but were not limited to, essential (primary) hypertension. A Physician's Order, dated 8/5/2025, indicated Resident 2 was to receive hydralazine 10 milligrams (mg) by mouth every 8 hours for essential hypertension. The medication was to be held if Resident 2's systolic blood pressure was less than120 millimeters of mercury (mmhg) the facility and was to call the physician if Resident 2's systolic blood pressure was greater than 150 mmhg, or if the resident's diastolic blood pressure was greater than 90 mmhg, or if the resident's diastolic blood pressure was less than 60 mmhg. On 1/1/2026 the medication administration record (MAR) indicated Resident 2's systolic blood pressure was 165/73 mmhg, which was greater than 160 mmhg systolic. The physician was not notified of the elevated systolic blood pressure. On 1/5/2026 the MAR indicated Resident 2's blood pressure was 193/99, which was greater than 160 systolic and 90 diastolic. The physician was not notified of the elevated systolic and diastolic blood pressures. On 1/12/2026 at 12:24 P.M. the DON indicated the physician should have been notified of the elevated blood pressures. She also indicated the facility did not have a policy for following physician orders or the plan of care as it is considered the standard of care.3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to assist a resident with eating during meal time for 1 of 2 residents reviewed for activities of daily living. (Resident 13)Finding includes:A record review for Resident 13 was completed on 1/9/2026 at 9:14 A.M. Diagnoses included, but were not limited to, cerebral infarction with hemiplegia/hemiparesis to left side, dementia, and dysphagia.A Quarterly Minimum Data Set (MDS) assessment, dated12/11/2025, indicated Resident 13 had severe cognitive impairment and required supervision and/or touch assist for eating needs.A current Care Plan problem, initiated on 9/23/2025, indicated Resident 13 was at risk for weight fluctuations and nutrition problems. Interventions indicated the resident was to eat in the assist dining room for supervision and cueing.During an observation on 1/7/2026 at 12:13 P.M., lunch had been served to Resident 13 at 12:01 P.M. At 12:13 P.M. the resident ate 1 bite of her chili soup. She then began taking spoonfuls of soup and dumping them onto her plate. Staff did not offer assistance or cueing to encourage Resident 13 to eat. At 12:22 P.M. Resident 13 told a CNA the chili was too hot. Upon clarification she meant spicy. She also asked for a cup of coffee. The CNA provided coffee but did not offer a substitute for the chili soup. During an observation on 1/8/2026 at 9:17 A.M., Resident 13 was seated at a table in the unit's common area with her breakfast tray in front of her. She was drinking her coffee, but her cereal had spilt in her lap and onto the floor. She attempted to eat a few pieces from her lap but staff made no attempt to assist her. At 9:29 A.M. a CNA asked her if she was done and the resident stated, No. However, the CNA removed the tray. The CNA then noted the spilled cereal and indicated she needed to go and take care of it. She then took the resident to her room, changed her top, and returned her to the table. No other food was offered to the resident. During an interview on 1/12/2026 at 12:24 P.M. the DON indicated the resident should have received assistance and have been offered substitutions for uneaten and spilled food, especially if she indicated she was not done. She also indicated the facility did not have a policy for following physician orders or the plan of care as it is considered the standard of care. 3.1-38(3)

Based on observation, record review and interview, the facility failed to follow the plan of care for 2 of 16 residents reviewed for vascular needs (Resident 54) and pressure relief (Resident 18).Findings include: 1.During an observation on 1/7/2025 at 2:59 P.M., Resident 54 was not been wearing Tubigrip (elastic tubular bandage providing continuous support for swelling) on either lower extremity. Resident 54's left foot and ankle had plus 2 pitting edema (swelling of the skin that takes 2 seconds to return to normal after pressing the skin with the index finger) and non-pitting edema (swelling of the skin that rebounds instantly when pushed on with index finger) on the right foot and ankle. During an interview on 1/7/2025 at 3:00 P.M., Resident 54 indicated the facility had not provided leg wraps for the edema (swelling) for either one of his lower legs or feet. During observations on 1/08/2026 at 9:16 A.M. and 2:10 P.M., Resident 54 was not wearing tubigrips. Resident 54's record review was completed on 1/9/2025 at 11:05 A.M. Diagnoses included, but were not limited to: stage 3 chronic kidney disease, fracture of the left femur and atrial fibrillation. A Quarterly Minimum Data (MDS) assessment dated , 12/19/2025, indicated Resident 54 had moderate cognitive impairment, had not rejected care or had any behaviors and received a diuretic (medication that makes the kidneys remove excess salt and water from the body). A current Physician's order initiated on 11/14/2025, indicated Resident 54 was to have Tubigrips applied to her bilateral lower extremities in the morning and removed at bedtime for edema. A review of Resident 54's January Treatment Administration Record (TAR) was reviewed on 1/9/2025 at 11:00 A.M. Although Resident 54 was observed without Tubigrips applied, on both 1/7/and 1/8, the January TAR had documented the resident as having worn the wraps. Resident 54's record lacked the documentation to indicate the resident had refused wearing Tubigrips on either one of his lower extremities. During an interview on 1/9/2025 at 1:00 P.M., the Regional Nurse Consultant (RNC) indicated Resident 54 had not been wearing Tubigrips and she would cancel the order because the resident had refused to wear the Tubigrips. The RNC indicated the TAR should not have been marked completed because the task had not been completed on 1/7 and 1/8/2025. 2. Resident 18 was observed laying in bed with her heels laying directly on the mattress during the following times:-1/7/2025 at 3:18 P.M.-1/8/2025 at 9:31 A.M.-1/8/2025 at 2:45 P.M.-1/9/2025 at 8:45 A.M. During an interview on 1/09/2026 at 9:48 A.M., a local Hospice Provider CNA indicated Resident 18's heels were not floated, but should have been. Resident 18's record review was completed on 1/9/2025 at 11:45 A.M. Diagnoses included, but were not limited to: chronic pulmonary obstructive disorder, anxiety disorder, chronic pulmonary edema and dysphagia. A Quarterly MDS assessment dated [DATE], indicated Resident 18 had moderate cognitive impairment, had not rejected care, had been receiving Hospice services and was at risk for pressure injury. A current Physician's order initiated on 12/25/2025, indicated Resident 18 was to have her heels floated (soft object placed under knees or calfs to lift heels) at all times, except during care. A review of Resident 18's January 2026 TAR indicated the resident's heels had been documented as having been floated on 1/7 and 1/8/2026, even though they had been observed not elevated and/or floated. There was no documentation that Resident 18's had refused floating of her heels on 1/7, 1/8 or 1/9/2026. During an interview on 1/9/2025 at 1:00 P.M., the Regional Nurse Consultant (RNC) indicated it was unclear why Resident 18's heels had not been floated and she would have to look into it. During an interview on 1/12/2025 at 12:30 P.M., the RNC indicated the facility did not have a policy for following Physician's orders, but the facility followed the Standards of Care and following the Physician's orders was included in the Standards of Care. The RNC indicated tasks should not have been marked as completed on the TARs if the task had not been completed. On 1/12/2025 at 10:26 A.M. the Director of Nursing (DON) provided a policy dated, 1/31/2024, and titled, Documentation in the Medical Record. The DON indicated the policy was the one currently used by the facility. The policy indicated, . 3. Principles of documentation include, but are not limited to: .b. Documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or responses 3.1-37

Based on observation, interview and record review, the facility failed to ensure staff providing wound care and directing wound and infection control measures in the facility was competent. (Employee 9) Finding includes:During an observation of Resident 6's wound care on 1/12/2026 at 11:06 A.M., the Wound Nurse/Infection Preventionist Nurse (WN/IPN) removed a dressing from Resident 6's right buttocks, removed the packing from the wound and took the protective dressing off of the resident's coccyx (a small triangular bone at the base of the spinal column). The WN/IPN inserted her index finger into the wound on the buttocks to assess the channeling of the wound, measured the wound with a cotton swab, cleaned the wound with a sterile saline solution, wiped a medicated pad around the wound's edges, applied medicated ointment around the wound, packed the wound with a medicated packing material and covered both the wound on the buttocks and the coccyx with clean bandages.Next, the WN/IPN repositioned the resident onto her back and provided urinary catheter care by cleaning the catheter with soap and water. The WN/IPN's gloves were not changed nor was hand sanitizer used after removing the dirty dressings, before applying the treatments, before or after applying the new bandages, nor before providing urinary catheter care.After the WN/IPN had provided the resident with urinary catheter care, the WN/IPN used hand sanitizer and changed her gloves. She then proceeded to remove a border gauze dressing from the resident's thigh wounds. Sterile saline was then used, followed by wiping a medicated pad around both wounds. The WN/IPN used the same medicated pad to wipe both wounds and the same cotton swab to measure both wounds and then applied a border gauze dressing to the wounds on the residents' left and right thigh. The WN/IPN gloves were not changed after she removed the old bandage and before treating, measuring or covering either thigh wound.Next, the WN/IPN removed the band aides from the resident's second and third toes. The WN/IPN did not change her gloves or use hand sanitizer after removing the bandages and before cleaning the 4th toe, measuring the wound or putting a clean bandage on the wounds.The WN/IPN then removed the dressing off Resident 6's left heal, measured the heal, used sterile saline to clean the heel, wiped a medicated pad around the wound, applied a collagen wound treatment , covered the wound with a bandage and then placed the resident's sock back on her foot. The WN/IPN did not use hand sanitizer or change her gloves after removing the dressing, before starting the treatment or before applying a clean bandage. During an interview on 1/12/2026 at 11:40 A.M., the WN/IPN indicated she had been changing dressings for over 20 years and did not needed to change her gloves or use hand sanitizer after removing dirty dressings, after applying treatments or before applying a clean bandage. The WN/IPN indicated she should have changed her gloves and used hand sanitizer before starting urinary catheter care. During an interview on 1/12/2026 at 11:45 A.M., the Director of Nursing (DON) indicated during wound care, gloves should be changed and hand sanitizer used after removing a dirty dressing, after completing the wound treatment and before applying a clean bandage. Although the WN/IPN's skills check off titled, Validation Checklist for Catheterization, and dated 5/29/2025, indicated the WN/IPN had been trained and observed for hand washing and wearing gloves before catheter care and the WN/IPN's skill check off title, Wound Care Observation Checklist for Infection Control, and dated 5/29/2025, indicated the WN/IPN had been trained and observed for hand hygiene before wound care treatment started, after removing the dirty dressing, after applying the treatment and before applying the clean bandage. It was unclear why the WN/IPN had indicated the hand sanitation and changing of gloves was not necessary during wound care and treatments.On 1/12/2025 at 10:46 A.M., the DON provided a policy, dated 6/12/2025 and titled, Enhanced Barrier Precautions, and identified the policy as the one currently used by the facility. The policy indicated, . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds, indwelling medical devices (e.g., central lines, urinary catheters, ventilator tubes/tracheostomy, hemodialysis catheters and PICC lines) even if the resident is not known to be infected or colonized by MDRO On 1/12/2025 at 1:46 P.M., the DON provided a policy, dated 1/29/2024 and titled, Catheter Care Policy, and identified the policy as the one currently used by the facility. The policy indicated, . Implementation Guidelines: . 7. perform hand hygiene 8. don gloves On 1/12/2025 at 10:46 A.M., the DON provided a policy, dated 7/16/2025 and titled, Wound Treatment Policy, and identified the policy as the one currently used by the facility. The policy indicated, . 2. All wound care shall be performed using appropriate infection control practices and per community guidelines 3.1-14(i)

Based on observation, interview and record review the facility failed to store and seal food in a sanitary manner related to sealing food appropriately in the walk-in cooler and failed to ensure serving utensils were clean in 1 of 1 kitchens. This had the potential to affect 53 of 53 residents who received their meals from the kitchen. Findings include: 1. During the initial kitchen tour with the Director of Food Services on 10/24/2024 at 9:43 A.M., the following was observed in the walk-in cooler: - a container of pickles was stored without a secure lid and was open to air. During an interview on 10/24/2024 at 9:45 A.M., the Director of Food Services indicated the lid of the pickles should have been secured. 2. During a follow-up kitchen tour with the Director of Food Services on 10/25/2024 at 9:45 A.M., the following was observed: - a metal scoop with dried food on it was stored in the clean utensils drawer. - a pair of metal tongs with dried food on it was stored in the clean utensils drawer. - the bottom of the clean utensils drawer had dried food and other debris. During an interview on 10/25/2024 at 9:52 A.M., the Director of Food Services indicated utensils should be clean before placing them in the drawers and the utensil drawer should have been cleaned. On 10/28/2024 at 11:27 A.M., the Director of Food Services provided the policy titled, Date Marking for Food Safety Policy, dated 4/17/2024 and indicated it was the policy currently used by the facility. The policy indicated, . 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to notify the physician of elevated blood glucose levels for 2 of 2 residents reviewed for blood glucose levels (Residents 7 and 3). Findings include: 1. On 10/28/2024 at 10:02 A.M., a record review was completed for Resident 7. Diagnoses included, but were not limited to: type 2 diabetes A Physician's order, dated 6/11/2024, indicated the physician was to be notified if Resident 7's blood glucose levels were below 70 or above 200. A review of Resident 7's blood glucose results for the months of August, September and October 2024 indicated the record lacked documentation the physician was notified of elevated blood glucose levels above 200 mg/dl for the following dates: - On 8/4/2024, Resident 7's blood glucose level was 263 mg/dL. - On 8/10/2024 the resident's blood glucose level was 276 mg/dL. - On 8/17/2024 the resident's blood glucose level was 319 mg/dl. - On 8/18/2024 the resident's blood glucose level was 222 mg/dL. - On 8/19/2024 the resident's blood glucose level was 236 mg/dL. - On 8/20/2024 the resident's blood glucose level was 210 mg/dL. - On 8/25/2024 the resident's blood glucose level was 301 mg/dL. - On 9/14/2024 the resident's blood glucose level was 266 mg/dL. - On 9/28/2024 the resident's blood glucose level was 221 mg/dL. - On 10/25/2024 the resident's blood glucose level was 258 mg/dL. During an interview, on 10/28/2024 at 11:17 A.M., the Director of Nursing (DON) indicated a nursing note should have been associated with Resident 7's elevated blood glucose levels indicating the physician had been notified and would have been found in the residents electronic medication administration record (EMAR). During an interview, on 10/28/2024 at 2:15 P.M., the DON indicated Resident 7's EMAR lacked documentation the physician was notified of the residents elevated blood glucose levels and she indicated the physician should have been notified. 44111 2. A record review was completed on 10/28/2024 at 10:08 A.M., for Resident 3. Diagnoses included, but were not limited to: type 2 diabetes mellitus with chronic kidney disease. A Physician's Order, dated 4/28/2023, indicated accuchecks were to be done weekly twice a day. The Physician the residents blood glucose level to be called if it was less than 70 or greater than 200. The Medication Administration Record (MAR) dated September 2024, indicated the following P.M. blood sugars: on 9/6/2024 was 321, and on 9/27/2024 was 221. The MAR dated October 2024, indicated the following P.M. blood sugars: on 10/4/2024 was 254 and on 10/18/2024 was 207. During an interview, on 10/28/2024 at 2:18 P.M., LPN 6 indicated when a physician was notified of an elevated blood sugar it would have been documented in the nursing progress notes. During an interview, on 10/28/2024 at 2:23 P.M., the DON indicated when a Physician was notified of an elevated blood sugar, the documentation could be found in a note with the order in the MAR, or in the nursing progress notes. DON was unable to locate in the electronic medical record any documentation of Resident 3's blood glucose levels of the Physician being notified. On 10/28/2024 at 2:44 P.M., the DON provided a policy titled, Blood Glucose Monitoring, revised 4/3/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: It is the policy of the facility to perform blood glucose monitoring to diabetic residents as per physician's orders. 20. Report critical test results to physician timely . 3.1-5(a)(2)

Based on interview and record review, the facility failed to provide a copy of the Bed Hold Policy to a resident when admitted to the hospital for 1 of 3 residents reviewed for hospitalization . Finding includes: A record review was completed on 10/28/2024 at 10:00 A.M. for Resident 4. Diagnoses included, but were not limited to, Alzheimer's Disease, chronic obstructive pulmonary disease and atrial fibrillation. A Nursing Progress Note, dated 9/7/2024, indicated Resident 4 had complained of shortness of breath and was confused at times. The resident's daughter indicated she thought the resident had pneumonia. The Medical Director was notified and gave an order for the resident be sent to the emergency room for an evaluation. An emergency room nurse called the facility and reported Resident 4 had pneumonia and was going to be admitted to the hospital. The record indicated the Notice of Transfer/Discharge was given but lacked documentation the Bed Hold Policy had been given to Resident 4. During an interview on 10/28/2024 at 11:04 A.M., the Employee 6 indicated a copy of the Bed Hold Policy, or documentation that it was given to the resident, was not located in the chart. On 10/30/2024 at 9:00 A.M., the MDS (Minimum Data Set) Nurse provided a copy of the Bed Hold Policy that should have been given to a resident when they were transferred and admitted to the hospital but the facility did not provide a policy indicating situations when the document was to be provided to the resident. 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to have Care Plan meetings, quarterly, with residents and/or resident representatives for 2 of 2 residents who were reviewed for Care Plan meetings. (Resident 6 & 7) Findings include: 1. During an interview on 10/24/2024 at 10:35 A.M., Resident 6 indicated she had not been invited to Care Plan meetings with the facility staff. Resident 6's record review was completed on 10/25/2024 at 2:56 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, hemiplegia of the right side, dysphagia, aphasia, vascular dementia and emphysema. A Quarterly Minimum Data Set (MDS) assessment, dated 9/24/2024, indicated Resident 6 had intact cognition. Resident 6's record lacked the documentation a Care Plan meeting had been conducted on a quarterly basis with Resident 6 and/or her representative from 11/29/2023 through 5/2/2024. During an interview on 10/29/2024 at 10:42 A.M., the Social Services Director (SSD) indicated Care Plan meetings were completed after a MDS assessment, or at minimum, quarterly. The SSD indicated Resident 6 should have had a Care Plan meeting after she received an MDS assessment on 1/31/2024. 2. During an interview on 10/24/204 at 10:45 A.M., Resident 7's representative indicated he could not remember being invited to a Care Planning meeting. Resident 7's record review was completed on 10/28/2024 at 10:02 A.M. Diagnoses included, but were not limited to: type 2 diabetes mellitus, sick sinus syndrome, cardiomegaly and adjustment disorder. A Quarterly MDS assessment, dated 9/24/2024, indicated Resident 7 had severe cognitive impairment. Resident 7's record lacked the documentation indicating she had a Care Plan meeting had been conducted between 11/27/2023 through 4/8/2024. During an interview on 10/29/2024 at 10:42 A.M., the Social Services Director (SSD) indicated Resident 7 should have had a Care Plan meeting after November 2023 and before April 2024. On 10/29/2024 at 10:00 A.M., the SSD provided a policy, dated 1/2024, titled, Care Plan Meetings, and identified it as the policy currently used by the facility. The policy indicated, .Care plan meetings must occur every three months, and whenever there is a major change in a resident's physical or mental health that might require a change in care 3.1-(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure infection control practices were followed by 1 of 1 staff observed cleaning an isolation room and 1 of 1 staff observed providing catheter care.(Housekeeper 3 and CNA 4). Findings include: 1. During an observation on 10/25/24 at 11:18 A.M., Housekeeper 3 was observed cleaning Resident 251's room. The resident was on contact precautions due to Clostridium difficile. Housekeeper 3 wore a pair of gloves, but did not have on a gown. The Assistant Director of Nursing (ADON) was overheard telling Housekeeper 3 that she needed to have a gown on when in a residents room because the resident was on contact precautions. Housekeeper 3 indicated she thought the sign on Resident 249's room, which read Enhanced Barrier Precautions, and the sign on Resident 251's room, which read Contact Precautions were both the same. During an observation and interview on 10/ 25/2024 at 11:29 A.M., Housekeeper 3 was observed cleaning another room after leaving Resident 251's room. Housekeeper 3 indicated she did not remember having any training on the differences between contact precautions and enhanced barrier precautions and stated she only remembered learning that it was important to knock prior to entering a residents room. She indicated she did not realize there was a difference between the sign on Resident 249's room and the sign on Resident 251's room. After reading the signs, she indicated she should have donned a gown prior to entering and cleaning Resident 251's room. During an interview on 10/25/2024 at 11:45 A.M., the ADON indicated Housekeeper 3 should have had a gown on prior to entering Resident 251's room. On 10/25/2024 at 1:38 P.M., a record review was completed for Resident 251. Diagnoses included, but were not limited to: entercolitis due to clostridium difficile. A Physician's Order, dated 10/22/2024 indicated Resident 251 may participate in activities outside the facility related to contact and droplet isolation. A review of Resident 251's Physicians Progress Notes indicated a positive Clostridium difficile result on 10/15/2024. 2. On 10/29/2024 at 9:35 A.M., a record review was completed for Resident 1. Diagnoses included, but were not limited to: neuromuscular dysfunction of bladder. A current Care Plan, initiated on 2/24/2020 indicated Resident 1 had an indwelling Foley catheter with the potential for infection related to neurogenic bladder and bladder spasms. Interventions included were to provided catheter care per protocol and Enhanced Barrier Precautions. During an observation of catheter care on 10/29/2024 at 10:20 A.M., CNA 4 put on a pair of gloves and a gown and removed Resident 1's brief. CNA 4 did not change her gloves prior to beginning catheter care. She proceeded to wash the resident's lower abdomen and under the residents abdominal folds. She then washed the residents perineal area and catheter without changing gloves or getting a clean wash cloth. CNA 4 then dried Resident 1 with a towel and applied a clean brief on the resident. During an interview on 10/29/2024 at 10:46 A.M., CNA 4 indicated she did not think she did anything wrong during catheter care. Upon further discussion, CNA 4 agreed she should have changed her gloves and used a clean wash cloth before providing catheter care. On 10/25/2024 at 12:05 P.M., the ADON provided the policy titled, Isolation Precautions, dated 6/5/2022 and indicated it was the policy currently being used by the facility. The policy indicated, Policy: it is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used for a resident. Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms which are spread by direct or indirect contact with the resident or the residents environment. Recommendations for personal protective equipment: Contact; Gowns whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle On 10/25/2024 at 12:06 P.M., the ADON provided the policy titled, Routine Cleaning and Disinfection Policy, dated 3/30/2024 and indicated it was the policy currently being used by the facility. The policy indicated, .1. Staff will look for precautions signage prior to entering a resident's room. a. Use standard precautions, including appropriate personal protective equipment, for all rooms, unless transmission based precautions are identified. b. Adhere to transmission-based precautions as indicated on precaution signs On 10/31/2024 at 10:44 A.M., the ADON provided the policy titled, Clostridium difficile (C.diff), dated 1/23/2024 and indicated it was the policy currently being used by the facility. The policy indicated, .8. Environmental infection control: a. Housekeeping team member(s) shall adhere to standard and contact precautions On 10/29/2024 at 2:10 P.M., the DON provided the policy titled, Catheter Care Policy, dated 1/29/2024 and indicated it was the one currently being used by the facility. The policy indicated, .Female: 9. Gently separate the labia to expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth, start at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter 3.1-18(a)

Based on record review and interview, the facility failed to ensure a Quarterly MDS (Minimum Data Set) assessment was completed accurately for 1 of 23 reviewed. (Resident 4) Finding includes: A record review was completed on 9/7/2023 at 2:57 P.M. Diagnoses included, but were not limited to: cancer, heart failure, peripheral vascular disease, and chronic kidney disease. A Quarterly MDS (Minimum Data Set) assessment, dated 9/7/2023, indicated Resident 4 required extensive assist of 1 staff for bed mobility, transfers, dressing, and toileting and did not receive a diuretic during the assessment period. A current physician order, dated 8/28/2023, indicated Resident 4 had received Torsemide, (a diuretic), 10 mg (milligrams) by mouth every other day, and would had received the diuretic medication 3 times during the assessment period. During an interview, on 10/26/2023 at 10:00 A.M., the MDS Coordinator indicated that she should have included the diuretic for 3 days on the Quarterly MDS assessment dated [DATE]. On 10/31/2023 at 11:11 A.M., the Director of Nursing provided the policy titled,MDS 3.0 Completion, dated 10/2020, and indicated the policy was the one currently used by the facility. The policy indicated .1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for 1 of 24 residents whose care plans were reviewed. (Resident 46) Finding includes: During an interview, on 10/23/2023 at 11:20 A.M., Resident 46 indicated there could be more activities available and he had requested to use the elliptical machine five days a week but hadn't been able to access the elliptical machine. A record review was completed, on 10/25/2023 at 2:00 P.M. Resident 46's diagnoses included, but were not limited to: heart failure, atrial fibrillation, sick sinus syndrome, macular degeneration, and legal blindness. A Quarterly MDS (Minimum Data Set), assessment dated [DATE], indicated Resident 46 had moderately impaired cognitive status, and required partial to moderate assistance for activities of daily living. A care plan, dated 6/19/2023, indicated Resident 46 preferred self-selected activities in room, socializing at meals, sunbathing, and running. The care plan listed one intervention: Place current month's large print activity calendar in resident's room for resident and staff reference. During an interview, on 10/26/2023 at 10:39 A.M., the Activities Director indicated she was responsible for the activities care plan for Resident 46. The Director of Activities indicated that Resident 46's care plan was not person centered but should have been. On 10/26/2023 at 11:30 A.M., the Director of Nursing provided a policy titled, Comprehensive Care Plans, dated of 5/20/2022, and indicated the policy was the one currently used by the facility. The policy indicated, .Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives 3.1-35(a)

Based on interview and record review, the facility failed to update the fall care plan with a new intervention after a fall for 1 of 2 residents reviewed for falls. (Resident 9) Finding includes: During an interview, on 10/24/23 at 9:16 A.M., Resident 9 indicated she had fallen out of bed about two months ago but couldn't remember the date. A record review for Resident 9 was completed, on 10/26/2023 at 3:13 P.M. The Quarterly Minimum Data Set (MDS) assessment, dated 8/25/2023, indicated Resident 9's cognition was moderately impaired. She required extensive assist of 1 staff for bed mobility and transfers. She was always incontinent of bladder but continent of bowel. Active diagnoses included, but were not limited to: cerebrovascular accident, hemiplegia or hemiparesis, and non-Alzheimer's dementia. A care plan, dated 10/5/2023, indicated Resident 9 had potential for falls related to decreased mobility, decreased safety awareness, incontinence, oxygen usage and tubing, medication usage, disease processes and weakness. Diagnoses included, but were not limited to: dementia, history of CVA with right sided hemiplegia and right ankle/hand contractures, weakness, unspecified abnormalities of gait and mobility, and difficulty in walking. Interventions included: Encourage use of a walker with gait belt for ambulation and gait belt for transfers, floors free from spills or clutter, and personal items within reach, including call light. A Interdisciplinary Note on 9/20/2023 indicated, Incident Date: 9/20/2023, Incident Time: 4:40:00, Incident Type: fall, Reason for Incident: CNA reported that she heard [Resident's name] calling for help and found her on her back on the floor left side of her bed., Resident Description: I was sleeping and then I fell , answered [Resident's name] when asked if she knew what happened., Staff Actions at the time of incident: Assessment done. Assisted x 3 back to bed. No apparent/visible injuries seen. VS taken along with Neuro's and all WNL. No complaints of any pain. She said she was a little dizzy, but after 15 mins, was asked again and the dizziness was gone. [Physician's name] called; no orders made. POA informed of the incident. During an interview, on 10/27/23 at 11:15 AM, the Director of Nursing indicated that the care plan for falls should have been updated after the fall on 9/20/2023 and was not. On 10/27/2023 at 11:35 A.M., the Director of Nursing provided a policy titled, Fall Prevention, dated 1/30/2023, and indicated the policy as the one currently used by the facility. The policy indicated, .9. When a resident experiences a fall, the facility will . f. Review the resident's care plan and update with new interventions, as indicated 3.1-35 (c)(1)

Based on observation, interview, and record review, the facility failed to provide grooming for a female resident with facial hair for 1 of 2 residents reviewed for activities of daily living. (Resident 206) Findings include: During an observation and interview, on 10/24/2023 at 10:32 A.M., Resident 206 indicated she had a large amount of chin hairs. She indicated she had a shower the day before and that staff were going to help her shave, but they came back and told her they did not have anything to shave her with. A record review was completed, on 10/25/2023 at 11:28 A.M. Resident 206's diagnoses included, but were not limited to atrial fibrillation, congestive heart failure, and type two diabetes. An Admission MDS (Minimum Data Set) assessment had not been completed due to the resident was just admitted on [DATE]. A care plan, dated 10/18/2023, indicated Resident 206 needed assistance with bed mobility, toileting, transfers, eating and bathing/hygiene related to weakness with a goal of being well groomed at all times. Interventions included but were not limited to: encouraged to complete activities of daily living for self as able, encourage and assist in maintenance of good grooming and dressing, and shower twice weekly. During an observation and interview, on 10/25/2023 at 3:00 P.M., Resident 206 was observed with a large amount of chin hairs present on her chin. She indicated no one came back to help shave her. During an observation and interview, on 10/26/2023 at 1:37 P.M., Resident 206 was sitting up in her chair in her room looking in her bedside mirror. She indicated that she would like her chin hairs shaved because they were long, and she was told they would help her after her shower but that did not happen. During an interview, on 10/26/2023 at 1:52 P.M., CNA 8 indicated that if chin hairs are visible that staff were supposed to clean up and trim the hairs for both males and females. She indicated that if she saw chin hairs on a woman that she would usually shave them even if it was not a shower day. During an interview, on 10/26/2023 at 1:59 P.M., CNA 9 indicated that she did not feel comfortable shaving residents so she would ask another care provider on her team to shave them. She indicated that if she noticed chin hairs on a woman, that she would ask someone else to shave them as she would be afraid of doing this for the resident. A policy was provided on, 10/30/2023 at 11:53 A.M., titled Activities of Daily Living, dated 4/14/2020, and indicated the policy was the one currently used by the facility. The policy indicated .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene 3.1-38 (a)(3)

Based on observation, interview, and record review, the facility failed to ensure that physician orders were followed and the physician notified of a missed medication for 1out of 13 reviewed for medication. (Resident 36) Finding includes: During an initial resident interview on 10/23/2023 at 10:28 A.M., Resident 36 indicated she was upset because the nurse could not find her eye drops for her left eye, they told her they must have lost them in the room, or the nurse stuck them in her pocket. Her eye lid was itchy, tender, swollen, red with bloody drainage and her vision was blurry. During an interview and observation on 10/23/2023 at 2:11 P.M., Resident 36 indicated she missed 2 doses of her eye drops and they could not locate them, so they called the pharmacy. She continued to complain of the discomfort. The left eye was red, swollen, tender with a scabbed over area. A record review for Resident 36 was completed on 10/25/2023 at 8:55 A.M. Diagnoses included, but not limited to: chronic respiratory failure with hypoxia, chronic diastolic heart failure, atrial fibrillation, and chronic kidney disease. A Physician Order, dated 10/18/2023 with an end date of 10/28/2023, indicated Tobramycin 0.3% eye drops (generic) Type ABT-Antibiotic Order- 2 gtts Left eye Four Times a Day For chalazion left eye. During an interview on 10/25/2023 at 10:17 A.M., RN 6 indicated that if a medication was not available, she would call the pharmacy and see why they did not have it and how soon it could be sent out. She would also check to see if it was available in the pyxis, and notify the doctor to see if she wanted to extend if it was an antibiotic. During an interview on 10/25/2023 at 10:32 A.M., RN 5 indicated when a resident's medication is not available, she would attempt to get it from the pyxis, then call the pharmacy to see if she could receive it stat (immediately). If the medication was an antibiotic, she would call the doctor to see if they wanted the medication extended. She indicated it happened the past week when a resident's eye drops went missing and she missed some doses. She thought the night nurse put it in her pocket; she checked the whole cart and the resident's room. She could not find any documentation in the ID (interdisciplinary) note only a note in the MAR indicating the medication was not available. She indicated a note should have been made in the ID. She indicated she would text the doctor when she needed something but was unable to show the doctor had been notified. During an interview on 10/25/2023 at 11:15 A.M., the Director of Nursing (DON) indicated she would expect her nurses, if a medication was not available, to notify the pharmacy and Physician. Documentation would be in the ID notes. The nurses notify the doctor by calling a cell phone, fax, or text to call. On 10/25 2023 at 12:57 P.M., the DON provided a policy titled, Unavailable Medications, revised 4/9/2019, and indicated the policy was the one currently used by the facility. The policy indicated . 5. If a resident misses a scheduled dose of the medications, staff shall follow procedures for medication error, including physician/family notifications, completion of a medication error report, and monitoring the resident for adverse reactions to omissions of the medication 3.1-37

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was cleaned per physician orders and humidifer bottles, and tubing was dated and stored adequately for 4 out of 4 reviewed for oxygen. (Resident 5, 37, 11 & 47) Findings include: 1. A record review was completed for Resident 5 on 10/26/2023 at 11:00 A.M. Diagnoses included, but were not limited to: atrial fibrillation, acute on chronic systolic and diastolic heart failure, and hypertension. A Physician Order, dated 8/1/2023, indicated albuterol sulfate 2.5 mg (milligram)/3 ml (milliliter) (0.083%) solution for nebulization (generic) - 1 vial inhalation three times a day for reactive airway disease. During an observation, on 10/26/2023 at 5:38 A.M., RN 4 went into Resident 5's room and removed the residents nebulizer equipment and place it in the plastic bag. During an interview, on 10/26/2023 at 5:43 A.M., RN 4 indicated the procedure was to rinse the mask and medication cup with water, place on a paper towel and cover with one until it dries. 2. A record review for Resident 37 was completed on 10/26/2023 at 11:00 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia. A Physician Order, dated 8/15/2023, indicated rinse nebulizer cup and mouthpiece with water after use, shake off excess, allow to air dry, every shift. A Physician Order, dated 11/9/2022, indicated Ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base) 3 ml nebulization solution, 1 vial inhalation three times a day for chronic obstructive pulmonary disease. Scheduled 6:00 A.M., 11:00 A.M. and 9:00 P.M. During an observation, on 10/26/2023 at 6:22 A.M., RN 4 entered the Resident 37's room removed his neb mask and placed it in the plastic bag. During an interview, on 10/26/2023 at 6:23 A.M., RN 4 indicated he should have rinse the mask and medication cup. During an interview, on 10/26/2023 at 10:21 A.M., the Director of Nursing indicated she would expect her nurses to take the mouth piece/mask off and rinse them and place on a clean paper towel to dry and when dried place back in a clean bag. On 10/26/2023 at 10:41 A.M., the Director of Nursing provided a policy titled, Nebulizer, revised 1/30/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Care of the Equipment: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing weekly per facility policy 47419 3. During an observation, on 10/23/2023 at 3:02 P.M., Resident 11 had an oxygen bag, dated 10/15/2023. The humidification bottle and oxygen tubing were not dated. During an observation, on 10/24/2023 at 10:08 A.M., Resident 11 had an oxygen bag, dated 10/15/2023. The humidification bottle and oxygen tubing were not dated. During an observation, on 10/25/2023 at 1:11 P.M., Resident 11 had an oxygen bag, dated 10/15/2023. The humidification bottle and oxygen tubing were not dated. During an observation, on 10/26/2023 at 9:22 A.M., Resident 11 had an oxygen bag, dated 10/15/2023. The humidification bottle and oxygen tubing were not dated. During an observation, on 10/26/2023 at 1:36 P.M., Resident 11's oxygen bag was dated 10/15/2023, the humidification bottle was now dated 10/26/2023 and the oxygen tubing remained undated. During an interview, on 10/26/2023 at 1:37 P.M., RN 6 indicated she just changed the humidification bottle and tubing, and indicated they should have been changed weekly on Sunday nights. 48054 4. During an observation, on 10/24/2023 at 10:51 A.M. Resident 5's oxygen tubing and humidification bottle were undated and no oxygen storage bag was present. During an observation, on 10/25/2023 at 10:19 A.M., Resident 5's oxygen tubing and humidification bottle were undated and a no storage bag was present. During an observation, on 10/26/2023 at 9:00 A.M. the oxygen tubing and humidification bottle for Resident 5 was not dated and no storage bag was present. A clinical record review was completed, on 10/26/2023 at 10:59 A.M. Resident 5's Physician's Orders included oxygen therapy at 2.5 liters per minute per nasal canula, ordered 10/17/2023. A Physician's Order, dated 8/1/2023, included: change the oxygen tubing weekly every Sunday on the night shift, change the humidifier bottle as needed, and to change and date the oxygen tubing bag weekly. The October 2023 treatment record indicated the last documented tubing change was completed on 10/15/2023. During an interview, on 10/26/2023 at 2:10 P.M., LPN 7 indicated the oxygen tubing is changed once a week on Sunday nights and there should be an orange sticker on the tubing. LPN 7 indicated the sticker was not present and should have been. 48145 5. During an observation on, 10/23/2023 at 3:16 P.M., Resident 47's oxygen tubing was undated. During an observation on, 10/24/2023 at 9:39 A.M., Resident 47's oxygen tubing was undated. During an observation on, 10/25/2023 at 8:23 A.M., Resident 47's oxygen tubing was undated. During an observation on, 10/26/2023 at 9:12 A.M., Resident 47's oxygen tubing was undated. A record review was completed on, 10/26/2023 at 11:37 A.M. Resident 47's diagnoses included, but were not limited to: chronic right heart failure, emphysema, pulmonary fibrosis. A Physician's Order, dated 9/15/2023, indicated Resident 47 had continuous oxygen at two liters nasal cannula. A Physician's Order, dated 9/15/2023, indicated oxygen tubing should be changed weekly on Sundays on the night shift. During an interview, on 10/26/2023 at 1:37 P.M., LPN 2 indicated there was no date on the oxygen tubing but there should have been a date. On 10/26/2023 at 10:41 A.M., the Director of Nursing provided a policy titled, Nebulizer, revised 1/30/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Care of the Equipment: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing weekly per facility policy On 10/26/2023 at 2:20 P.M., the Director of Nursing provided a policy titled, Oxygen Administration, dated 1/30/2023, and indicated the policy was the one currently used by the facility. The policy indicated, .5b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, and weekly per facility policy, or as recommended by the manufacturer 3.1-47 (a)(6)

Based on observation, interview and record review, the facility failed to recognize a missed medication as a medication error and notify the pharmacy and physician for 1 out of 14 residents interviewed. (Resident 36) Finding includes: During an initial resident interview on 10/23/2023 at 10:28 A.M., Resident 36 indicated she is upset because the nurse could not find her eye drops for her left eye, they told her they must have lost them in the room, or the nurse stuck them in her pocket. Her eye lid was itchy, tender. swollen, red with bloody drainage and her vision was blurry. During an interview and observation on 10/23/2023 at 2:11 P.M., Resident 36 indicated she missed 2 doses of her eye drops and they could not locate them, so they called the pharmacy. She continued to complain of the discomfort. The left eye was red, swollen, and tender with a scabbed over area. A record review for Resident 36 was completed on 10/25/2023 at 8:55 A.M. Diagnoses included, but not limited to: chronic respiratory failure with hypoxia, chronic diastolic heart failure, atrial fibrillation, and chronic kidney disease. A Physician Order, dated 10/18/2023 with an end date of 10/28/2023, indicated Tobramycin 0.3% eye drops (generic) Type ABT-Antibiotic Order- 2 gtts Left eye Four Times a Day For chalazion left eye. During an interview on 10/25/2023 at 10:17 A.M., RN 6 indicated that if a medication was not available, she would call the pharmacy and see why they did not have it and how soon it could be sent out. She would also check to see if it was available in the pyxis, and notify the doctor to see if she wanted to extend if it was an antibiotic. During an interview on 10/25/2023 at 10:32 A.M., RN 5 indicated when a resident's medication is not available, she would attempt to get it from the pyxis, then call the pharmacy to see if she can get it stat (immediately). If the medication was an antibiotic, she would call the doctor to see if she wanted the medication extended. It happened the past week when a resident's eye drops went missing and she missed some doses. She thought the night nurse put it in her pocket; she checked the whole cart and resident's room. She could not find any documentation in the ID notes only a note in the MAR indicating the medication was not available. There should have been a ID note. She would text the doctor when she needed something but was unable to show the doctor was notified. During an interview on 10/25/2023 at 11:15 A.M., the Director of Nursing (DON) indicated she would expect her nurses if they had a medication error, she would expect them to call the pharmacy and notify the doctor to get further orders. Documentation would be in the ID notes. They do an incident report if the wrong medication is given to another resident but not for a missed or late medication, they do not do a med error report. The nurses would notify the doctor by calling her cell phone, fax, or text for her to call them. On 10/25 2023 at 12:57 P.M., the DON provided a policy titled, Unavailable Medications, revised 4/9/2019, and indicated the policy was the one currently used by the facility. The policy indicated . 5. If a resident misses a scheduled dose of the medications, staff shall follow procedures for medication error, including physician/family notifications, completion of a medication error report, and monitoring the resident for adverse reactions to omissions of the medication On 10/25/23 at 12:57 P.M., the DON provided a policy titled, Medication Error Policy, revised 4/2019, and indicated the policy was the one currently used by the facility. The policy indicated .1. The facility shall ensure medications will be administered as follows: a. According to physician's orders 3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure a resident with severe cognitive deficits, who was identified as a high risk for elopement and wore a wanderguard (electronic wander management device), did not exit the building unattended for 1 of 3 residents reviewed for elopement, of 14 residents at risk for elopement. (Resident B) The Immediate Jeopardy began on 12/9/21 at 11:36 P.M., when Resident B was last observed on the facility's video surveillance system exiting the facility. The resident spent the night outside, and was located by a staff member 7 ½ hours later, on 12/10/21 at 7:10 A.M. The Administrator was notified of the Immediate Jeopardy on 12/20/21 at 1:56 P.M. The deficient practice was removed, and the deficient practice corrected on 12/17/21, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During a tour of the kitchen, on 12/20/21 from 9:50 A.M. - 9:54 A.M., an entrance/exit door from the dining room to the kitchen area was observed. In the kitchen, on the other side of the room, was another exit door to an employee corridor with an entrance/exit door to an outside dock area with a sidewalk/driveway which led to the employee parking lot. A facility self-reported incident, dated 12/10/21 at 7:10 A.M., indicated Resident B was found outside the facility and staff had been unaware of her location. An investigation was conducted and it was determined the resident was able to gain access to the kitchen and exited from the loading dock. On 12/20/21 at 10:58 A.M., a review of Resident B's clinical record was conducted. The resident's diagnoses included, but were not limited to: dementia, adult failure to thrive and muscle weakness. The Annual Minimum Data Set (MDS) Assessment, dated 11/24/21, indicated the resident had severe cognitive deficits and had wandering behaviors daily, with no risk of getting outside the facility, and she wore a wander/elopement alarm daily. A Care Plan, dated 3/2/21, indicated the resident was at risk of an elopement. The interventions included, but were not limited to: apply wanderguard to wrist and monitor placement/function, if attempting to leave re-direct and conduct an at risk to wander assessment per policy. The Elopement Assessment, dated 11/29/21, indicated resident was high risk for an elopement and wore a wanderguard. A Progress Note, dated 12/10/21, indicated .resident was found outside wondering [sic] in back of building, resident has no explanation on how and why she got out the building, when first found BP [Blood Pressure] was 183/99 HR [heart rate] 98, temp [temperature] 96.0, at 7:15 am, when resident was found, knees to pants and shoes had dirt on them, no injuries or alterations to skin noted, resident had no change in LOC [Level of Consciousness], at 7:45 am BP was 153/97, temp 96.4, HR 86, [resident daughter's name] was notified .will continue to monitor, full body assessment was performed, resident has redness and swelling to ankles, which is usual, also has slight redness to right side of scalp and right ear, resident is currently in bed resting with no pain noted The local area weather history for December 10, 2021, indicated the temperature at 12:54 A.M. was 38 degrees , at 4:13 A.M., the temperature was 34 degrees and at 7:12 A.M., the temperature was 31 degrees. During an interview on 12/20/21 at 11:12 A.M., Resident B's daughter indicated she was told about the elopement the day they found her mother outside near a maintenance truck. Her mother told her the day before she had seen her husband outside in his truck. The administrator had called her early on 12/10/21 indicating her mother had been outside overnight and spent time in the maintenance truck. He reported her mother was seen on a camera going through a door, into the kitchen, walked through the kitchen, out a door to an employee corridor between 11:00 P.M. -11:30 P.M., and then walked out the outside door. The door locked behind her. She was seen walking towards the parking lot but that was as far as the camera could see her. She and her brother had seen her mom that day and she was fine. The facility had assessed her thoroughly and they did not feel the need to send her to an emergency room . She indicated her mother was a DNR (Do Not Resuscitate). She feels that her mother is safe, as they had put a lock on the dining room door which goes into the kitchen. On 12/20/21 at 11:35 A.M., the resident was observed awake and in the bathroom, with a CNA combing her hair. A wanderguard was observed on her left wrist. The resident was alert to self only. On 12/20/21 at 2:10 P.M., the video of the resident's elopement was observed with the Maintenance Director and the Administrator. On 12/9/21 at 11:33 P.M., Resident B was observed entering the kitchen through the dining room door. She was viewed to walk through the kitchen and exit into the corridor at 11:34 P.M. The resident headed toward the exit door and looked out the window, then at 11:36 P.M., she walked out the door. She was viewed on the video to proceed down the walkway/driveway toward the employee parking lot and out of view. The resident was wearing shoes, sweat pants and sweat shirt, but no coat. The Maintenance Director indicated there was no other camera view out in the parking lot. The Administrator indicated the resident was located the next morning near a maintenance truck. The truck door was open and blankets were inside, in a different location per the Maintenance Director. They both believed the resident spent time inside the truck with the blankets. On 12/20/21 at 3:48 P.M., the Administrator indicated he was unable to conclude why staff did not realize the resident was not in the building, as he had statements from two staff members who were assigned to Resident B stating they seen her that night, which he believed was not possible. He indicated there had never been a wanderguard alarm on the door when entering the kitchen from the dining room nor on the employee exit door, where the resident had exited the facility. During an interview, on 12/21/21 at 9:32 A.M., RN 3 indicated she had worked the night shift and on the morning of 12/10/21, as she was pulling away from her parking spot when she noticed a lady standing near the facility trucks. One of the truck doors was open and the lady was having difficulty standing and she thought it looked like a resident. (RN was not assigned the hallway where the resident resides and she was employed with an Agency) She went to the lady, asked her name, called the Director of Nursing and then assisted her back into the building. She was not involved in assessing the resident after she was back inside the building. On 12/20/21 at 11:10 A.M., the Administrator provided a current policy titled, Elopement and Unsafe Wandering, dated 2/2020 and revised on 12/2021. The policy indicated .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk The past noncompliance immediate jeopardy began on 12/09/21. The immediate jeopardy was removed and the deficient practice corrected by 12/17/21, after the facility implemented a systemic plan that included the following actions: the facility placed an alarm and locks on doors that could lead to an exit door, conducted house-wide elopement education, implemented an elopement binder for each unit with updated elopement risk assessments for each resident and conducted elopement drills until a pattern of compliance was maintained. This Federal tag relates to complaint IN 177. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to prevent resident's from being abuse, protect residents from potential abuse, and ensure allegations of verbal abuse and psychological harm were thoroughly investigated or reported to the Administrator for 4 of 6 residents reviewed for abuse. This deficiency had the potential to affect 57 of 57 residents who resided in the facility. (Resident B, Resident H, Resident J and Resident K) The Immediate Jeopardy began on 8/18/16 when the facility failed to prevent potential psychological harm by placing Resident J in a demeaning position and not investigating how the resident was effected, and was identified on 2/17/17. The Administrator and the Director of Nursing (DON) were notified on 2/17/17 at 4:00 P.M. The Immediate Jeopardy was removed on 2/21/17, but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview, on 2/15/17 at 12:55 P.M., Resident B indicated she had problems with CNA (Certified Nursing Assistant) #3. She indicated CNA #3 would say things under her breath thinking no one heard it. The resident indicated the CNA made her feel like it was an inconvenience for CNA #3 to care for her and her husband. She heard CNA #3 say she was tired of the residents getting up and down from their beds and refused to put her husband in bed when he asked. The resident indicated she had reported the incidents to the staff, her daughter, the DON and to the Ombudsman. On 2/15/17 at 1:15 P.M., a record review for Resident B was conducted. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 12/1/16, indicated the resident's Brief Interview for Mental Status (BIMS) was 15 (normal cognition), required supervision of 1 person with transfers and toileting. During an interview, on 2/15/17 at 1:28 P.M., Resident B's daughter indicated CNA #3 was rude to her mother and made comments behind her back. The daughter had told the DON multiple times about the issues and then spoke to the Ombudsman. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file had an Employee Coaching and Counseling Form, dated 10/18/16. The form indicated Resident B reported she no longer wants CNA #3 to care for her, as resident heard CNA #3 say .This one will be fun and I'm tired of people getting up and down The form indicated the DON spoke with CNA #3, told her to be respectful at all times and .CNA was to care for resident today There were no other notes and/or investigations regarding the incident with Resident B. There was no indication the Administrator was notified and the incident was not reported to ISDH. 2. On 2/16/17 at 2:30 P.M., the Administrator provided 2 incidents, for review, which were reported to the Indiana State Health Department (ISDH). One incident was reported to ISDH and involved Resident K and CNA #3. The incident form, dated 11/14/16 at 2:01 P.M., indicated Resident K .was upset and tearful and stated she was afraid of the nursing assistant. Resident was interviewed by the Assistant Director of Nursing and later by the Administrator The incident follow up, dated 11/21/16, indicated .Following our investigation, I have decided to terminate this nursing assistant. Based on our interviews with the resident and staff, I determined that there was no verbal or physical abuse of any kind. However, the staff member caused unintentional fear in the resident by not talking with her during care .We have spoken to this staff member before regarding non-verbal communication in terms of body language and tone when interacting with resident The form was submitted by the Administrator and the Staff member involved was CNA #3. A form titled Investigation of (Resident K's name) Complaint, undated, indicated the resident was afraid of CNA #3 and had concerns regarding the CNA when she left her on the toilet to long, while standing just outside the restroom door. Resident K indicated in the report CNA #3 told resident the devil was going to get her and did not hand the resident a call light after CNA #3 took her to her room. The investigation indicated several staff members were interviewed, but no staff names were documented and no other residents were included in the investigation report. A termination Evaluation Form, located in the employee's file indicated CNA #3's last day to work at the facility was 11/14/16 and her termination date was 11/21/16. 3. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file included a form titled Conflict Resolution Meeting, dated 8/18/16. The form indicated CNA #3 told a resident .to have his BM (bowel movement) on the floor and housekeeping would clean it up. This was overhead by (housekeeper's name) who was cleaning a toilet behind the curtain The form indicated CNA #3 was very upset about Housekeeper #2 reporting the incident to the DON. There was no name of the resident on this form. The resident's name was requested from the DON. During an interview, on 2/17/17 at 11:20 P.M., the DON indicated Resident J was the resident who was told to have his bowel movement on the floor. She indicated there was a restroom in the shower room. She had no other notes/investigations regarding the incident with Resident J. On 2/18/17 at 1:00 P.M., a review of the clinical record for Resident J was conducted. The resident's [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 1/20/17, indicated the resident's BIMS was 15 (normal cognition), required the assist of 1 person for toileting and personal hygiene. During an interview, on 2/18/17 at 1:52 P.M., Resident J indicated he had been told to poop on the floor in the shower room on 8/18/16. 4. During an interview, on 2/15/16 at 8:14 P.M., the complainant indicated she was concerned about several incidents in the facility, which had been brought to her attention. She felt the facility was allowing a culture of abuse by not thoroughly investigating incidents involving Resident B and Resident H. On 2/16/17 at 10:28 A.M., Resident H was observed in the Activity area. She had been playing bingo and was ready for another game. She was sipping on a drink. Her clothes were clean. On 2/16/17 at 10:30 A.M., a review of the clinical record for Resident H was conducted. The record indicated the resident's [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/27/16, indicated the resident's BIMS was 6 (severe dementia). During an interview, on 2/17/17 at 5:00 P.M., the Social Service Director (SSD) described an event which happened in the facility sometime the end of July or the first of August in 2016. He had been in a meeting near his office when he heard screaming in the hallway. His interim, at the time, went to the hallway to see what was going on. She returned and asked him to come help her. The SSD observed LPN (Licensed Practical Nurse) #4 standing over Resident H and screaming at the resident I can't take her anymore and I can't take this anymore. The SSD indicated the resident was crying. The SSD told LPN #4 she needed to leave. He proceeded to assist the resident into his office to separate her from the LPN. He calmed the resident and took her to an activity in her unit. When he returned LPN #4 was in the DON's office and she started to scream at him. The SSD told the DON the LPN needed to go home. He had no notes on the incident, but indicated the DON and the Administrator were both aware of the incident. The SSD indicated the LPN did not leave the building the day of the incident. He inquired to Human Resources if a report was completed regarding the incident, but he was told they couldn't give him any information from an employees file. On 2/17/17 at 10:30 A.M., LPN #4's employee file was received from the Business Office Manager. The file indicated LPN #4 was terminated on 2/14/16 due to chronic tardiness and attendance problems. On 2/17/17 at 3:40 P.M., an interview was conducted with the Administrator and the DON. The DON indicated she had no recollection of the incident with Resident H and LPN #4 and had no notes on the incident. The Administrator indicated he was not aware of the incident neither, therefore there was no incident report sent to ISDH. The DON indicated the incident with Resident J was not about the resident, the form was about a conflict resolution between the two staff members. The DON indicated she did not think Resident J was abused. On 2/15/17 at 3:35 P.M., the Administrator provided a policy titled Abuse, Neglect and Exploitation, dated November 28, 2016. and indicated the policy was the one currently used by the facility. The policy indicated .The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: *Administrator *Other Officials in accordance with State Law * State Survey and Certification agency through established procedures . 7. Investigation of Alleged Abuse, Neglect and Exploitation. -When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview resident several times to compare responses. b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. d. Document the entire investigation chronologically The Immediate Jeopardy that began on 8/18/16 was removed 2/21/17, when, through interviews and record reviews, staff had completed education regarding abuse and abuse prohibition. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The facility administration contracted an outside authority to perform education on abuse to administrative staff and complete ongoing monitoring of all allegations of abuse. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of ongoing monitoring to ensure residents are free from abuse. This Federal tag relates to complaint IN 136. 3.1-28(a) 3.1-28(c) 3.1-28(d)

Based on interview, and record review, the facility failed to ensure their abuse policy and procedure was implemented regarding protecting residents from abuse and the investigations of verbal abuse and/or psychological harm for 4 of 4 allegations reviewed. This deficiency had the potentia to affect 57 of 57 residents who resided in the facility. (Resident B, Resident H, Resident J and Resident K) The Immediate Jeopardy began on 8/18/16 when the facility failed to prevent potential psychological harm by placing Resident J in a demeaning position and not investigating how the resident was effected, and was identified on 2/17/17. The Administrator and the Director of Nursing (DON) were notified on 2/17/17 at 4:00 P.M. The Immediate Jeopardy was removed on 2/21/17, but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview, on 2/15/17 at 12:55 P.M., Resident B indicated she had problems with CNA (Certified Nursing Assistant) #3. She explained CNA #3 would say things under her breath thinking no one heard it. The resident indicated CNA made her feel like it was an inconvenience for CNA #3 to care of her and her husband. She heard CNA #3 say she was tired of the residents getting up and down from their beds and refused to put her husband in bed when he asked. The resident indicated she had reported the incidents to the staff, her daughter, the DON and to the Ombudsman. During an interview, on 2/15/17 at 1:28 P.M., Resident B's daughter indicated CNA #3 was rude to her mother and made comments behind her back. The daughter had told the DON multiple times about the issues and then spoke to the Ombudsman. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file had an Employee Coaching and Counseling Form, dated 10/18/16. The form indicated Resident B reported she no longer wanted CNA #3 to care for her, as resident heard CNA #3 say .This one will be fun and I'm tired of people getting up and down The form indicated the DON spoke with CNA #3, told her to be respectful at all times and .CNA was to care for resident today There were no other notes and/or investigations regarding the incident with Resident B. There was no indication the Administrator was notified and the incident was not reported to ISDH. On 2/16/17 at 4:10 P.M., a time card for CNA #3 was received from the Business Office Manager. The time card indicated the CNA clocked in on 10/18/16 at 6:36 A.M. and clocked out at 2:32 P.M., on the day the allegation of abuse was reported. 2. On 2/16/17 at 3:30 P.M., an incident form, dated 11/14/16 at 2:01 P.M., was received from the Administrator. The form indicated Resident K .was upset and tearful and stated she was afraid of the nursing assistant .Resident was interviewed by the Assistant Director of Nursing and later by the Administrator The incident follow up, dated 11/21/16, indicated .Following our investigation, I have decided to terminate this nursing assistant. Based on our interviews with the resident and staff, I determined that there was no verbal or physical abuse of any kind. However, the staff member caused unintentional fear in the resident by not talking with her during care .We have spoken to this staff member before regarding non-verbal communication in terms of body language and tone when interacting with resident The form was submitted by the Administrator and the Staff member involved was CNA #3. On 2/16/17 at 4:10 P.M., a time card for CNA #3 was received from the Business Office Manager. The time card indicated the CNA #3's last day she clocked in to work was 11/14/16. She worked 6:30 A.M. and clocked out for the day at 2:38 P.M. 3. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file included a form titled Conflict Resolution Meeting, dated 8/18/16. The form indicated CNA #3 told a resident .to have his BM (bowel movement) on the floor and housekeeping would clean it up. This was overhead by (housekeeper's name) who was cleaning a toilet behind the curtain The form indicated CNA #3 was very upset about Housekeeper #2 reporting the incident to the DON. During an interview, on 2/17/17 at 11:20 P.M., the DON indicated Resident J was the resident who was told to have his bowel movement on the floor. She indicated there was a restroom in the shower room. She had no other notes/investigations regarding the incident with Resident J. On 2/16/17 at 4:10 P.M., a time card for CNA #3 was received from the Business Office Manager. The time card indicated the CNA clocked in on 8/18/16 at 6:38 A.M. and clocked out at 2:37 A.M. 4. During an interview, on 2/17/17 at 5:00 P.M., the Social Service Director (SSD) described an event which happened in the facility sometime the end of July or the first of August in 2016. He had been in a meeting near his office when he heard screaming in the hallway. His interim, at the time, went to the hallway to see what was going on. She returned and asked him to come help her. The SSD observed LPN #4 standing over Resident H and screaming at the resident I can't take her anymore and I can't take this anymore. The SSD indicated the resident was crying. The SSD told LPN #4 she needed to leave. He proceeded to assist the resident into his office to separate her from the LPN. He calmed the resident and took her to an activity in her unit. When he returned LPN #4 was in the DON's office and started to scream at him. The SSD told the DON the LPN needed to go home. He had no notes on the incident, but indicated the DON and the Administrator were both aware of the incident. The SSD indicated the LPN did not leave the building the day of the incident. He inquired to Human Resources if a report was completed regarding the incident, but he was told they couldn't give him any information from an employees file. On 2/17/17 at 3:40 P.M., an interview was conducted with the Administrator and the DON. The DON indicated she had no recollection of the incident with Resident H and LPN #4 and had no notes on the incident. The Administrator indicated he was not aware of the incident neither, therefore there was no incident report sent to ISDH. The DON indicated the incident with Resident J was not about the resident, the form was about a conflict resolution between the two staff members. The DON indicated she did not think Resident J was abused. On 2/15/17 at 3:35 P.M., the Administrator provided a policy titled Abuse, Neglect and Exploitation, dated November 28, 2016. and indicated the policy was the one currently used by the facility. The policy indicated .The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: *Administrator *Other Officials in accordance with State Law * State Survey and Certification agency through established procedures . 7. Investigation of Alleged Abuse, Neglect and Exploitation. -When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview resident several times to compare responses. b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. d. Document the entire investigation chronologically .9. Response and Reporting Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should .b. Notify the Director of Nursing and Administrator (document) c. Initiate an investigation immediately .e. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately The Immediate Jeopardy that began on 8/18/16 was removed 2/21/17, when, through interviews and record reviews, staff had completed education regarding abuse and abuse prohibition. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The facility administration contracted an outside authority to perform education on abuse to administrative staff and complete ongoing monitoring of all allegations of abuse. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of ongoing monitoring to ensure residents are free from abuse. This Federal tag relates to complaint IN 136. 3.1-28(a)

Based on observation, record review and interviews, the facility failed to administer the facility in a manner to ensure management implemented the abuse policy and procedures, to protect residents' which resulted in a Partial Substandard Quality of Care. This deficient practice had the potential to affect 57 of 57 residents in the facility. Findings include: Based on specific information denoted in a complaint; residents, a family member and staff were interviewed regarding abuse, including an allegation of verbal for Residents B and Resident H. In the process of the investigation two other allegations of abuse were discovered. During an interview, on 2/15/16 at 8:14 P.M., the complainant indicated she was concerned about several incidents in the facility, which had been brought to her attention. She felt the facility was allowing a culture of abuse by not thoroughly investigating incidents involving Resident B and Resident H. 1. During an interview, on 2/15/17 at 12:55 P.M., Resident B indicated she had problems with CNA (Certified Nursing Assistant) #3. She explained CNA #3 would say things under her breath thinking no one heard it. The resident indicated CNA made her feel like it was an inconvenience for CNA #3 to care for her and her husband. She heard CNA #3 say she was tired of the residents getting up and down from their beds and refused to put her husband in bed when he asked. The resident indicated she had reported the incidents to the staff, her daughter, the Director of Nursing (DON) and to the Ombudsman. During an interview, on 2/15/17 at 1:28 P.M., Resident B's daughter indicated CNA #3 was rude to her mother and made comments behind her back. The daughter had told the DON multiple times about the issues and then spoke to the Ombudsman. 2. On 2/16/17 at 3:30 P.M., an incident form, dated 11/14/16 at 2:01 P.M., was received from the Administrator. The form indicated Resident K .was upset and tearful and stated she was afraid of the nursing assistant .Resident was interviewed by the Assistant Director of Nursing and later by the Administrator The incident follow up, dated 11/21/16, indicated .Following our investigation, I have decided to terminate this nursing assistant. Based on our interviews with the resident and staff, I determined that there was no verbal or physical abuse of any kind. However, the staff member caused unintentional fear in the resident by not talking with her during care .We have spoken to this staff member before regarding non-verbal communication in terms of body language and tone when interacting with resident The form was submitted by the Administrator and the Staff member involved was CNA #3. 3. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file included a form titled Conflict Resolution Meeting, dated 8/18/16. The form indicated CNA #3 told a resident .to have his BM (bowel movement) on the floor and housekeeping would clean it up. This was overhead by (housekeeper's name) who was cleaning a toilet behind the curtain The form indicated CNA #3 was very upset about Housekeeper #2 reporting the incident to the DON. There was no name of the resident on this form. The DON indicated the incident involved Resident J. During an interview, on 2/18/17 at 1:52 P.M., Resident J indicated he had been told to poop on the floor in the shower room but explained they don't do that anymore. 4. During an interview, on 2/17/17 at 5:00 P.M., the Social Service Director (SSD) described an event which happened in the facility sometime the end of July or the first of August in 2016. He had been in a meeting near his office when he heard screaming in the hallway. His interim, at the time, went to the hallway to see what was going on. She returned and asked him to come help her. The SSD observed LPN (Licensed Practical Nurse) #4 standing over Resident H and screaming at the resident I can't take her anymore and I can't take this anymore. The SSD indicated the resident was crying. The SSD told LPN #4 she needed to leave. He proceeded to assist the resident into his office to separate her from the LPN. He calmed the resident and took her to an activity in her unit. When he returned LPN #4 was in the DON's office and started to scream at him. The SSD told the DON the LPN needed to go home. He had no notes on the incident, but indicated the DON and the Administrator were both aware of the incident. The SSD indicated the LPN did not leave the building the day of the incident. He inquired to Human Resources if a report was completed regarding the incident, but he was told they couldn't give him any information from an employees file. On 2/17/17 at 3:40 P.M., an interview was conducted with the Administrator and the DON. The DON indicated she had no recollection of the incident with Resident H and LPN #4 and had no notes on the incident. The Administrator indicated he was not aware of the incident neither, therefore there was no incident investigation and/or report sent to ISDH. The DON indicated the incident with Resident J was not about the resident, the form was about a conflict resolution between the two staff members. The DON indicated she did not think Resident J was abused. There was no comment from the Administrator concerning resident J. On 2/15/17 at 3:35 P.M., the Administrator provided a policy titled Abuse, Neglect and Exploitation, dated November 28, 2016. and indicated the policy was the one currently used by the facility. The policy indicated .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately .b. Have evidence that all alleged violations are thoroughly investigated .c. Prevent further potential abuse, neglect exploitation, or mistreatment while the investigation is in process .d. Report the results of all investigation to the administrator .The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and report the results of the investigation when final, as required by state agencies This Federal tag relates to complaint IN 136. 3.1-13(q)

Based on observation, interview and record review, the facility failed to ensure 4 of 6 residents reviewed, were free from verbal abuse and/or psychological harm. (Resident B, K, J and H) Findings include: 1. During an interview, on 2/15/17 at 12:55 P.M., Resident B indicated she had problems with CNA (Certified Nursing Assistant) #3. She explained CNA #3 would say things under her breath thinking no one heard it. The resident indicated CNA made her feel like it was an inconvenience for CNA #3 to care for her and her husband. She heard CNA #3 say she was tired of the residents getting up and down from their beds and refused to put her husband in bed when he asked. The resident indicated she had reported the incidents to the staff, her daughter, the DON (Director of Nursing) and to the Ombudsman. On 2/15/17 at 1:15 P.M., a record for Resident B was conducted. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 12/1/16, indicated the resident's Brief Interview for Mental Status (BIMS) was 15 (normal cognition), required supervision of 1 person with transfers and toileting. During an interview, on 2/15/17 at 1:28 P.M., Resident B's daughter indicated CNA #3 was rude to her mother and made comments behind her back. The daughter had told the DON multiple times about the issues and then spoke to the Ombudsman. 2. On 2/16/17 at 3:30 P.M., an incident form, dated 11/14/16 at 2:01 P.M., was received from the Administrator. The form indicated Resident K .was upset and tearful and stated she was afraid of the nursing assistant .Resident was interviewed by the Assistant Director of Nursing and later by the Administrator The incident follow up, dated 11/21/16, indicated .Following our investigation, I have decided to terminate this nursing assistant. Based on our interviews with the resident and staff, I determined that there was no verbal or physical abuse of any kind. However, the staff member caused unintentional fear in the resident by not talking with her during care .We have spoken to this staff member before regarding non-verbal communication in terms of body language and tone when interacting with resident The form was submitted by the Administrator and the Staff member involved was CNA #3. 3. On 2/16/17 at 3:00 P.M., an employee file for CNA #3 was received from the Business Office Manager. The employee file included a form titled Conflict Resolution Meeting, dated 8/18/16. The form indicated CNA #3 told a resident .to have his BM (bowel movement) on the floor and housekeeping would clean it up. This was overhead by (housekeeper's name) who was cleaning a toilet behind the curtain The form indicated CNA #3 was very upset about Housekeeper #2 reporting the incident to the DON. There was no name of the resident on this form. The DON indicated the incident involved Resident J. On 2/18/17 at 1:00 P.M., a review of the clinical record for Resident J was conducted. The resident's [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 1/20/17, indicated the resident's BIMS was 15 (normal cognition), required the assist of 1 person for toileting and personal hygiene. During an interview, on 2/18/17 at 1:52 P.M., Resident J indicated he had been told to poop on the floor in the shower room but explained they don't do that anymore. Resident J was observed in his room, sitting in his wheelchair. His clothes were clean and he indicated today was his shower day. 4. On 2/16/17 at 10:28 A.M., Resident H was observed in the Activity area. She had been playing bingo and was ready for another game. She was sipping on a drink. Her clothes were clean. On 2/16/17 at 10:30 A.M., a review of the clinical record for Resident H was conducted. The record indicated the resident's [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/27/16, indicated the resident's BIMS was 6 (severe dementia). During an interview, on 2/17/17 at 5:00 P.M., the Social Service Director (SSD) described an event which happened in the facility sometime the end of July or the first of August in 2016. He had been in a meeting near his office when he heard screaming in the hallway. His interim, at the time, went to the hallway to see what was going on. She returned and asked him to come help her. The SSD observed LPN (Licensed Practical Nurse) #4 standing over Resident H and screaming at the resident I can't take her anymore and I can't take this anymore. The SSD indicated the resident was crying. The SSD told LPN #4 she needed to leave. He proceeded to assist the resident into his office to separate her from the LPN. He calmed the resident and took her to an activity in her unit. When he returned LPN #4 was in the DON's office and started to scream at him. The SSD told the DON the LPN needed to go home. He had no notes on the incident, but indicated the DON and the Administrator were both aware of the incident. The SSD indicated the LPN did not leave the building the day of the incident. He inquired to Human Resources if a report was completed regarding the incident, but he was told they couldn't give him any information from an employees file. On 2/17/17 at 3:40 P.M., an interview was conducted with the Administrator and the DON. The DON indicated she had no recollection of the incident with Resident H and LPN #4 and had no notes on the incident. The Administrator indicated he was not aware of the incident neither, therefore there was no incident report sent to ISDH. The DON indicated the incident with Resident J was not about the resident, the form was about a conflict resolution between the two staff members. The DON indicated she did not think Resident J was abused. On 2/15/17 at 3:35 P.M., the Administrator provided a policy titled Abuse, Neglect and Exploitation, dated November 28, 2016. and indicated the policy was the one currently used by the facility. The policy indicated .Each Resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .2. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability The policy indicated the facility would prevent abuse by .k. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds This Federal tag relates to complaint IN 136. 3.1-27(1) 3.1-27(b)

Based on observation, record review and interview, the facility failed to identify Resident A's risk of an accident. The resident fell from her bed which resulted in a right femur fracture and an extended hospital stay. This affected 1 out of 1 resident, Resident A. Finding includes: Resident A's clinical record was reviewed on 9/22/2014 at 1:45 p.m. Resident A's [DIAGNOSES REDACTED]. Resident A's Brief Interview for Mental Status (BIMS), dated 9/8/2014, indicated a score of 15, cognitively intact. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident A hygiene care was an extensive assistance with two plus person physical assist. A nursing note, dated 4/2/14 at 4:32 p.m., indicated "...2 assist required for transfers which are accomplished using Hoyer lift. Assistance required for all ADL's (Activities of Daily Living)...." Review of an incident report indicated "On August 20, 2014 at 10:45 AM, staff member was providing care to resident who was lying on a pressure relieving air mattress. The mattress was set on the firm setting to allow staff to re-position the resident as necessary. After 15 minutes, the mattress automatically deflates to the softer setting to prevent future skin breakdown. This occurred while the staff member was still providing care. The staff member pushed the button for the mattress to return to the firm setting causing the resident to roll out of bed." The report further indicated the resident was assessed for potential injury. The resident complained of right hip pain. The physician was notified and the resident was sent to the hospital for evaluation. The resident sustained [REDACTED]. The Admission Register, 8/21/2014 thru 9/21/2014, indicated Resident A was re-admitted to the facility on [DATE] from hospital. Consultation Final Report (name of health system), dated 8/20/2014, indicated "...There is an acute displaced comminuted fracture of the proximal right femur...." During an interview on 9/23/2014 at 2:30 p.m., The DON (Director of Nursing)indicated the air mattress control box had an audio instructor. The audio instructor gives operating instruction which informs the listener that the air mattress will deflate after 15 minutes at maximum firmness. During an interview on 9/24/2014 at 9:07 a.m., LPN #1 indicated before the fall of Resident A on 8/20/2014 she did not know about the air mattress deflating after 15 minutes of maximum firmness. She indicated she trained herself on the function of the air mattress. During an interview on 9/24/2014 at 9:19 a.m., CNA #1 indicated she was the only one in the room with Resident A. After positioning Resident A on the left edge of the bed, CNA #1 provided personal care and positioned the Hoyer lift sling. CNA #1 indicated she was not aware if Resident A was not in the center of the bed when air mattress inflated Resident A would fall. During an observation of a demonstration and interview with CNA#1 on 9/24/2014 at 9:55 a.m., CNA #1 demonstrated what happened on 8/20/2014 when Resident A fell out of bed onto the floor which resulted in a fractured right femur and a six day hospital stay. The air mattress control box was attached to the foot board of Resident A's bed. There were 2 buttons to control the firmness of the mattress. Button number one was for elevation support which includes eating, watching TV and visiting. Button number 2 was for maximum firmness needed during personal care, repositioning, transferring and wound care. The maximum firmness setting deflates automatically to the normal air mattress firmness after 15 minutes. On 8/20/14, CNA #1 pressed the number 2 button on the air mattress controls panel for the maximum firmness. Resident A was positioned toward the left edge of the bed with her back toward the CNA #1. CNA #1 provided private area care to Resident A. Then, CNA #1 started to positioned the Hoyer lift sling under the Resident A and the air mattress automatically started to deflate. CNA #1 reached to the end of the bed and pressed button number two button to reinflate the mattress to maximum firmness. As the mattress started to inflate, Resident A's feet and legs went over the side of the bed causing the resident's body to follow resulting in a fracture to the right femur. This Federal tag relates to Complaint IN 530. 3.1-45(a)(2)

Based on observation, record review and interviews, the facility failed to ensure a dependent resident was safely positioned in a speciality bed which resulted in a fall with fractures for 1 of 3 residents reviewed with a history of falls in a sample of 3. (Resident "B") Findings include: During the initial tour, on 12/17/12 between 9:30 a.m. and 10:15 a.m., while accompanied by the ADNS (Assistant Director Nursing Services), Resident "B" was identified as sustaining a fall from a speciality bed which resulted in fracture of the (L) (left) tibia and (L) fibula. The resident was identified as unable to stand independently, dependent for mobility needs and interviewable. The record of Resident "B" was reviewed on 12/17/12 at 2:00 p.m. Resident "B" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS ( Minimum Data Set: a tool used to assess for care needs of residents) dated 08/31/12, indicated the resident was cognitive, required extensive assistance of 2 + (two plus) persons for: Bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed ...) as well as transfers and toileting. The MDS indicated the resident's "Functional Limitation in Range of Motion -...limitation that interfered with daily functions or placed resident at risk of injury" was impairment of upper extremity (shoulder, elbow, wrist, hand) on one side and impairment of lower extremity (hip, knee, ankle, foot) on both sides. Review of nurses notes indicated: "11-11/12 11 a.m. Resident request to be placed on (L) side to move bowels. Stated "foot fell of (sic) bed causing chain reaction & (and) fell out of bed." Heard yell from room when staff arrived resident was lying on floor on back. C/O (complained/of) (arrow down: lower) body pain. ROM (range of motion) WNL (within normal limits) - (Physician's name) & mother (name) notified. New order x-ray (arrow down) body pain...." "11-11-12 6 p.m. Received copy of x-ray from (company name). called to (physician's name) N.O. (new order) received to send pt to (hospital name) for eval (evaluation)...." Review of the x-ray report indicated: "Radiology Interpretation...IMPRESSION: Interval fracture of the tibia, nondisplaced, with joint space effusion proximal tibia. It is difficult to evaluate...Left Tibia-Fibula: The fracture of the proximal tibia described as previously stated...Theses images do demonstrated a nondisplaced fracture of the proximal tibia and proximal fibula as well....IMPRESSION: 1. Fractures of the proximal tibia and fibula. 2. The shafts of the left tibia and fibula are intact." Review of a care plan, titled "Constipation-07/07/11," indicated an undated addition: "11. Res (resident) requests to lay on side p (after) supp (suppository) to facilitate results. Ensure res. is positioned in ctr (center of bed)." CNA #5 was interviewed on 12/18/12 at 10:15 a.m. CNA #5 indicated she was the CNA normally assigned to Resident "B" and was providing care the day of the fall. CNA #5 indicated the bed's mattress was very slick. CNA #5 indicated she positioned Resident "B" as usual, turning her to her (R) (right) side. CNA #5 believed the resident was in the center of the bed and Resident "B" indicated she was also. The bed did not have siderails or bolsters. CNA #5 indicated she asked the resident if she was ok to leave alone, as usual, and the resident indicated she was. CNA #5 indicated she checked the resident twice without incident. CNA #5 indicated she entered the room and Resident "B" yelled and indicated the had fallen out of bed. When queried, CNA #5 indicated staff do not stay with Resident "B" while toileting. CNA #5 had not been inserviced on the bed and staff do not do anything special with it. Resident "B" was interviewed on 12/18/12 at 10:30 a.m. Resident "B" was observed sitting in her motorized wheelchair. The resident's bed was observed to be in the lowest position and the surface of the mattress of a smooth/slick blue material. Resident "B" indicated she thinks she slid off the bed because she was not in the middle of the bed prior to being turned to her side for toileting needs. Resident "B" indicated being aware of being too close to the edge of the bed when she began to fall. Resident "B" indicated the mattress surface is very slick but did not think mattress was the cause of the fall but her placement on the bed. Resident "B" indicated one person will "normally" stay with her but "not consistently." Resident "B" indicated staff always ask if it's ok to leave unattended before doing so. The DNS (Director Nursing Services) was interviewed on 12/18/12 at 2:00 p.m. The DNS indicated Resident "B" is the only resident in the facility utilizing this brand of speciality mattress. The DNS indicated the mattress, which preceded the DNS's employment with the facility, does not have any specific instructions in regards to usage. The DNS indicated the facility did not have a policy and procedure on its usage and Resident "B" was not care planned for the mattress. The DNS indicated the surface was slick. This Federal tag relates to Complaint IN 951. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure allegations of physical and verbal abuse were reported to State authorities as required, and in accordance with the facility's policy for 2 of 4 residents (Residents: #B, #D) reviewed for abuse in the sample of 4 and 2 of 6 residents (Residents: #F, #G) in the supplemental sample of 6. The immediate jeopardy began on 7/05/11 when Resident # F, who was recovering from recent back surgery, reported to CNA #3 on 7/4/11 that CNA #2 had thrown her into bed and left her sideways in the bed. Resident # F then reported the incident on 7/5/11 to the Director of Nursing who failed to suspend CNA #2 and protect other residents from potential harm during investigation of the alleged abuse. The Administrator and the Director of Nursing (DON) were notified of the immediate jeopardy at 5:30 P.M. on 7/13/11. The immediate jeopardy was: removed on 7/15/11, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Review of a facility "Incident Report," dated 5/3/11, indicated, "...(Resident #B) alleges that on Monday, 5-2-11, a CNA who gave her a shower treated her roughly and had a "bad attitude." She reported that she was sprayed in the face with the shower sprayer...." A"Resident/Family Concern Report," dated 5/3/11, and signed by the Chaplain, indicated, "Nature of Concern: Resident (#B) reported rough handling and bad attitude of CNA #8 when resident asked repeatedly for bed pan last week. Resident #B thought she had asked 'someone in charge' to not have this CNA (#8) help with her care. Last evening, 5/2/11, (CNA #8) came to do (Resident #B's) shower. (Resident #8) reported she was sprayed in the face, and (CNA #8) was not following her wishes concerning (Resident #B's) clothing...." During interview with the DON on 7/12/11 at 2:30 P.M., she indicated she was unaware Resident #B requested CNA #8 not be assigned to provide her care. An "Investigation" report, dated 5/4/11 and signed by RN #9, indicated, "...The previous week Nurse (LPN #10) had called (Name), DON re: (regarding) a conflict between (Resident #B) and (CNA #8). (Resident #B) did not want (CNA #8) in her room. I was working Wing 200 that nite (sic) and overheard the phone conversation at the nurses station on Wed., April 27th." Review of CNA's Personnel File on 7/11/11 at 3:20 P.M. lacked documentation of an investigation, a State reportable, counseling, or disciplinary action regarding the issue reported by LPN #10 regarding Resident #B's accusation of alleged rough handling by CNA #8 when assisting her with the bedpan (4/27/11). Resident #B's closed clinical record was reviewed on 7/11/11 at 3:45 P.M., and indicated [DIAGNOSES REDACTED]. An initial MDS (Minimum Data Set) Assessment, dated 4/15/11, indicated she was moderately cognitively impaired with a score of 12 out of 15. 2. The closed clinical record of Resident #D was reviewed on 7/12/11 at 10:45 A.M. and indicated [DIAGNOSES REDACTED]. During interview with Resident #D's daughter on 7/11/11 at 2:15 P.M., Resident #D's daughter indicated her mother had told her that a night CNA cussed at her, threw her in bed, and told her "I'm tired of you using that d--n call light. I'm tired of coming into your room. "My mother complained 'They're mean to me. They're mean to me.' I, at first, thought my mother was imagining it, but when the bruises and tremors were evident, I went to the DON with my concerns. I told her mother described the CNA as (race stated), tall woman. The DON said, 'We don't have a tall (race stated) girl working here.' My mother was lying in bed and looking up at the individual which probably made her look tall." In a second interview with Resident #D's daughter on 7/12/11 at 9:20 A.M., she indicated she asked her mother if she could remember the name of the CNA who was rough with her. "It was a (race stated) girl in the middle of the night." "She did complain to the DON (Name) about the treatment. We were very upset when the bruises were discovered at the hospital. Mother remembers them shoving her around and slamming her into bed and she told them, 'Be careful your going to break my hip, again.' " Review of Resident #D's initial MDS (Minimum Data Set) Assessment, dated 5/18/11, indicated she was cognitively intact with a score of 15 out of 15. During interview with the DON on 7/12/11 at 10:35 A.M., she indicated she was able to validate with the resident that the CNA was just hurrying. She further indicated, as a result, she did not feel there was a need to do a State Reportable. The Nursing staff schedule was reviewed and indicated CNA #15 was the only (race stated) CNA who provided care to Resident #D on the night shift. The May and June, 2011 schedules indicated CNA was assigned to provide care to Resident #D on the following dates: 5/24, 5/31, 6/7, 6/14, 6/18, and 6/19/11. CNA #15's Personnel File was reviewed on 7/12/11 at 4:15 P.M. and lacked documentation or any proof of investigation regarding Resident #D or her family's alleged abuse by CNA #15. Resident #D's clinical record also lacked documentation of alleged abuse or investigation of any alleged abuse. During interview with CNA #14 on 5/13/11 at 5:50 A.M., she indicated residents frequently complained to her about a particular CNA refusing to toilet a resident. "I overheard (CNA #15) being rude to a resident. I heard her tell the resident, 'I can't take you to the bathroom again. You just went 10 minutes ago.' Three or four of us girls have gone to the nurse's, but nothing seems to be done about it." LPN #16 indicated in an interview on 5/13/11 at 5:45 A.M., One night (CNA #15) came to me and told me she was tired of answering (Resident #G's) call light and I would have to do it. (CNA #15) said, "She's getting on my nerves." When queried if she reported it to the Supervisor she stated, "No, but I talked about it with the other nurse." During interview with CNA #17 on 7/13/11 at 5:50 A.M., she indicated a resident complained to her that she was left in bed. CNA #15 would not take her to the bathroom when she needed to go. "She wasn't soiled, but she really gushed when I took her." 3. Resident #F's clinical record was reviewed on 7/13/11 at 4:00 P.M. and indicated [DIAGNOSES REDACTED]. During interview with CNA # 4 on 7/13/11 at 5:25 A.M., she indicated several residents have complained to her about CNA #15 being rough with them. When queried who those residents were, she indicated Resident #F and Resident #G. Her information lead to conducted interviews with both Resident #F and Resident #G. (However, Resident #F indicated in the interview on 7/13/11 that it was CNA #2 who allegedly abused her.) Resident # F was identified as alert and oriented to person, place, and time by her physician in a History and Physical Report, dated 6/14/11, and by Social Service Staff #5 during an interview on 7/13/11 at 12:00 P.M. Resident #F's 14 day MDS (Minimum Data Set) Assessment, dated 6/17/11, indicted she was cognitively intact. She was admitted to the facility on [DATE] from an acute hospital. During interview with Resident #F on 7/13/11 at 9:15 A.M., she indicated that about 2 weeks ago, CNA #2 came into her room to assist her to the bathroom. CNA #2 insisted on putting Resident #F's back-brace on while she was sitting down. Resident #F told CNA #2 that Physical Therapist #6 told her she should be standing when the brace is put on her. CNA #2 responded, "I'll do it my way." Resident #F let her put the brace on while sitting because she was desperate to get to the bathroom. When she finished in the bathroom, CNA #2 assisted her to her bed. Resident #F, again, confronted CNA #2, this time regarding the position of the side rail on the bed. Resident #F informed CNA #2 that Physical Therapist #6 taught her to get into bed with the side rail down so she could position her body up higher on the mattress. CNA #2 replied in a snotty manner, "I'm not the therapist." Resident #F indicated she was sitting on the side of the bed when CNA #2 grabbed her by the sleeve and pulled her down toward the foot of the bed. "She then pushed my shoulders down on the bed, threw the pillow from my w/c onto the bed along with a sheet I used to cover my lap, and left me there. When she got angry her face got as red as an apple. I was afraid my back would get injured. I just had surgery and I don't want to have gone through all that pain for nothing. I'm just beginning to recover." Resident #F indicated she could not get anyone to help her, but when she saw CNA #3 outside her room she waved to her and she came to offer assistance. "She said, Oh dear, what happened to you? I told her what CNA #2 had done to me." Resident #F indicated CNA #3 had a physical condition which restricted her ability to lift, but together they managed to get her up in the bed. "She rescued me." When queried about the incident and what Resident #F was feeling at the time, she indicated she was fearful of CNA #2. .Resident #F indicated CNA #2 no longer provided her care, "I feel better that she isn't near me, but I would feel better if I didn't have to see her." Resident #F indicated she told the Director of Nursing (DON) the next day about CNA #2 and how she had frightened her. She indicated the DON was shocked and stated she had never had any problems with CNA #2 in the past. "She told me CNA #2 would not be assigned to take care of me again." She further indicated the DON told her if she filed a report there could be legal ramifications as a result. The DON indicated in an interview on 7/13/11 at 11:00 A.M. that she had not suspended CNA #2 because Resident #F did not mention to her that CNA #2 threw her into bed, but that she was bossy and put her into the bed and left her feet hanging off the bed. "Forty-five minutes later, when I sought clarification, Resident #F told me her feet were on the bed and she used her foot to get her call light." The DON further indicated CNA #2 was one of her best workers. Resident #F's clinical record lacked documentation of an investigation, a State Reportable, counseling, or disciplinary action regarding the issue reported to the DON on 7/5/11 by Resident #F.. During an interview with the DON on 7/13/11 at 2:30 P.M., evidence of an investigation of the incident between Resident #F and CNA #2 on 7/4/11 was requested from the DON. The DON indicated she would retrieve it from her office but, just minutes later, the DON was observed interviewing LPN #7 regarding the incident that had been reported 8 days previously (7/5/11). The DON admitted she had not written up an investigation. When queried if she could produce any of the report, she produced a statement by CNA #2, dated 7/5/11. There was no other documentation which indicated suspension, investigation, counseling, or disciplinary action had taken place. In her statement of 7/5/11, CNA #2 relayed a completely different story of the incident. CNA #2 indicated Resident #F wanted to go to the bathroom and get into bed, but she informed the resident that the nurse would like her to sit up in the recliner. "She told me to put down the side rail. I told her to let me show her how we transfer with the rail up, so she could grab it. I helped he (sic) into bed and lifted her legs into bed. She got mad at me for not putting down the side rail and asked to see the nurse." CNA #2 indicated she went to LPN #7 and told her two or three times that Resident #F wanted to see her, but LPN #7 was too busy. The DON was observed on 7/13/11 at 2:45 P.M., writing the statement Resident #F provided her on 7/5/11, but was unable to produce documentation to indicate other residents and staff had been interviewed as part of an investigation. During a telephone conversation on 7/13/11 at 2:50 P.M. with CNA #3, while in the presence of the DON and with the "speaker phone" on, CNA #3 indicated she found Resident #F sideways in her bed. She further indicated Resident #F told her CNA #2 "threw her into bed and left her there." CNA #3 and LPN #7 failed to report the incident to the DON, but Resident #F had voiced mistreatment to her on 7/5/11. 4. During interview with Resident #G on 7/13/11 at 10:35 A.M., she indicated she was fearful of using her call light because she had been yelled at by a staff person for having to go to the bathroom so much. "She would get angry when I had to go the bathroom. She was yelling 'Ever since they removed the catheter you've been a problem.' When someone knocks, I jump. I told them I was sorry, but I couldn't help it. Every time this need comes up (to use the bathroom) I get frightened. Recently, I had my light on, but no one came. I hurt because the pressure was so great. I took my blanket and folded it into a square and tucked it under me so I could pee on it without getting the rest of my bed wet. I reported that to (Social Service Staff #5) and the DON. Social Service Staff #5 indicated in an interview on 7/13/11 at 12:00 P.M. that he had been made aware of the situation and he met with Resident #G to discuss her feelings. He indicated this latest incident with the lack of a call light being answered happened on Monday, 7/11/11. "Resident #G has impaired vision and she was uncertain of the time, but she believed it was early morning around 5:00 A.M." During interview with the DON on 7/13/11 at 5:00 P.M., regarding the allegations made by Resident #G during interview with her on 7/13/11, she indicated she is still investigating the call light issue. Review of an "Internal Investigation" report, dated 4/15/11, indicated, "Date of Occurrence: 4/2/11? or 4/3/11 Saturday night. Description of Occurrence: (Resident #G) c/o (complained of) a staff member complaining that she wants to go to the bathroom a lot and that her hands hurt after she grabbed her by the hands to take her into the bathroom...." A "Resident Statement" report, dated 4/4/11, indicated, "Sometimes I have vision and I can see...I think it was during the night or late evening. It was all about me having to go to the bathroom. This person was saying that I need to go to the bathroom all of the time. There was a time when I was. She said I had a problem. She was angry kind of. She said we need to do something about it...My hands are tender and she took me by the hands to take into the bathroom. They are sore...." A written statement by RN # 11, undated, indicated, "At 12 A (12:00 A.M.) 4/3/11, (Resident #G) began to tell me of an incident that she said happened last night. Attempted to clarify the time frame, but she was unsure. I gathered enough information to call in the morning to on call Supervisor. 7:45 A. M.-When I called LPN #12 (Supervisor), she called DON (Name) and requested a full statement and body check. Resident asked to tell what happened as it occurred. Resident (#G) didn't remember putting on call light, but someone came in, (Resident #G) said yelling at her. The following are statement contents and what she remembers. "You go (urinate) more than anyone I know." Resident (#G) said she needed to go to the bathroom. "I know this is all about going pee"...Someone grabbed her hands and was rough moving her around. "You need to do something about your bladder. You need to get your bladder checked. There is something wrong with you." Resident (#G) replied, "That may be true). (Resident #G) used the word 'forceful.' The person kept talking throughout the event to the bathroom and back. (Resident #G) said her face felt hot, and she was shaking all over...she said her hands hurt when they grabbed them...." The "Internal Investigation" further indicated Resident G's son made the statement, "I think this story about someone complaining about her going to the bathroom a lot comes from when she was first here. I know she is really sensitive when it comes to her arms and wrists...." Report "Conclusion: (Resident #G) suffers from confusion. Statements from staff are providing nothing conclusive. Her son seems to think that she is repeating an old idea...." Resident #G's clinical record indicated she was admitted to the facility from an acute care hospital on [DATE]. A "Resident/Family Concern Report," dated 4/18/11 and signed by the DON, indicated, "Concerning Resident #G Nature of Concern: This writer noted resident coming down the hall in her wheelchair being pushed by (CNA #13), I asked (Resident #G) how she was doing. She said, 'Not very good right now.' Upon further questioning she complained that one of the CNA's complained that she was 'peeing' too much....I questioned (CNA #8), the other CNA in her room this afternoon. (CNA #8) said 'I didn't say that, I just took her to the bathroom." Explained to CNA (#8) that resident's many times have (sic) to urinate frequently for different reasons and that we can't judge this. We merely take them to the bathroom...Resolution and Disposition: "...CNA apologized to resident. A letter to the Indiana State Department of Health, dated 5/9/11, which included the Incident Report (regarding CNA #8 and another accusation by Resident #B) indicated, "...(CNA #8) was also involved on 4/18/11 in a complaint made by another resident, (Resident #G). She indicated that two CNA's complained that she urinated too frequently. One of these CNA's was (CNA #8)...." Resident #G's clinical record and the Personnel File of CNA #8, lacked documentation that the 4/2/11 and the 4/18/11 complaint of alleged abuse by Resident #G were reported to State authorities. It was briefly mentioned (21 days later) in the above letter and incident report, dated 5/9/11. Review of Resident #G's clinical record on 7//13/11 at 10:00 A.M., indicated [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) Assessment, dated 5/31/11, indicated Resident #G's vision was severely impaired, she was occasionally incontinent of urine, and needed limited assistance of one for toileting. She scored 11 of 15 for cognicity, which indicated she was moderately impaired. Review of a facility policy titled "Primary Abuse Prohibition Policy," dated 9/2000, indicated, "Policy: It shall be the policy of Southfield Village that all residents of this facility are free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion...Policy/Procedure ...Abuse-Identification of...Procedure: 1. ...staff and supervisory personnel will be cognizant of the potential for abuse of residents...2. The Administrator will be responsible for monitoring quality assurance and quality improvement progress reports for patterns, occurrences and trends that would be suggestive of abuse, neglect, ...within the facility. 3. The Administrator will be responsible for monitoring incident/accident reports for potential abuse...Investigation...Procedure: ...3. Staff incidents which involve abuse, neglect, ...are investigated as follows: 3.1 The staff member is suspended immediately without pay pending investigation. It is the intent of the facility to finalize an investigation within 3-5 days...." The immediate jeopardy that began on 7/5/11 was removed on 7/15/11 when the facility suspended the staff accused of alleged abuse and began investigations, began immediate mandatory in-services on proper protocols to follow regarding abuse and neglect, reviewed facility's abuse policy and procedure and found it to be reasonable and accurate, met with all management staff and on-call nursing staff to review protocol for reporting abuse, revised the daily stand-up meeting form to include allegations of abuse and neglect, notified the facility Medical Director of the immediate jeopardy, posted phone numbers of the Administrator and Director of Nursing in multiple locations of the facility with instructions to immediately report any allegation of abuse at any time, ensured the Administrator or her designee will monitor abuse protocol by randomly interviewing five residents per week for no less than six months, and ensured the facility will continue to provide abuse and neglect education upon hire and at least twice annually, but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure staff continued to recognize and report abuse and monitor staff to ensure they continued to follow the corrective action plan. This Federal tag relates to complaint IN 132. 3.1-28(c) 3.1-28(d)

Based on interview and record review, the facility failed to implement their written protocol regarding abuse and neglect to ensure staff recognized allegations of physical and verbal abuse and immediately reported those allegations to the Administrator for investigation to prevent the abuse from reoccurring. This deficient practice affected 2 of 4 residents (Residents: #B, #D) reviewed for abuse in the sample of 4 and 2 of 6 residents (Residents: #F, #G) in the supplemental sample of 6 with the potential to affect all 60 residents residing in the facility. The immediate jeopardy began on 7/05/11 when Resident # F, who was recovering from recent back surgery, reported to CNA #3 on 7/4/11 that CNA #2 had thrown her into bed and left her sideways in the bed. Resident # F then reported the incident on 7/5/11 to the Director of Nursing who failed to suspend CNA #2 and protect other residents from potential harm during investigation of the alleged abuse. The Administrator and the Director of Nursing (DON) were notified of the immediate jeopardy at 5:30 P.M. on 7/13/11. The immediate jeopardy was: removed on 7/15/11, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Review of a facility "Incident Report," dated 5/3/11, indicated, "...(Resident #B) alleges that on Monday, 5-2-11, a CNA who gave her a shower treated her roughly and had a "bad attitude." She reported that she was sprayed in the face with the shower sprayer...." A"Resident/Family Concern Report," dated 5/3/11, and signed by the Chaplain, indicated, "Nature of Concern: Resident (#B) reported rough handling and bad attitude of CNA #8 when resident asked repeatedly for bed pan last week. Resident #B thought she had asked 'someone in charge' to not have this CNA (#8) help with her care. Last evening, 5/2/11, (CNA #8) came to do (Resident #B's) shower. (Resident #8) reported she was sprayed in the face, and (CNA #8) was not following her wishes concerning (Resident #B's) clothing...." During interview with the DON on 7/12/11 at 2:30 P.M., she indicated she was unaware Resident #B requested CNA #8 not be assigned to provide her care. An "Investigation" report, dated 5/4/11 and signed by RN #9, indicated, "On Monday, May 2nd, approx (approximately) 9:00 P.M., I entered (Resident #B's) (room number) with her H.S. (bedtime) meds (medications). (CNA #8) had just showered her. (Resident #B) said to me: 'I don't know what is wrong with that girl. I don't like the way she handles me. When I saw her face I knew I was in for it'...The previous week Nurse (LPN #10) had called (Name), DON re: (regarding) a conflict between (Resident #B) and (CNA #8). (Resident #B) did not want (CNA #8) in her room. I was working Wing 200 that nite (sic) and overheard the phone conversation at the nurses station on Wed., April 27th." Review of the "CNA Evening Assignment," dated 5/2/11, indicated CNA #8 had been assigned to (Resident #B's) room. Review of CNA #8's personnel File on 7/11/11 at 3:20 P.M. lacked documentation of an investigation, a State Reportable, counseling, or disciplinary action regarding the issue reported by LPN #10 regarding Resident #B's accusation of alleged rough handling by CNA #8 when assisting her with the bedpan (4/27/11). An "Employee Counseling Form," dated 5/3/11, indicated CNA #8 was suspended 5/3/11 pending investigation. The DON indicated in the interview on 7/12/11 at 2:30 P.M. that CNA #8 had been terminated on 5/9/11. Resident #B's closed clinical record was reviewed on 7/11/11 at 3:45 P.M., and indicated [DIAGNOSES REDACTED]. An initial MDS (Minimum Data Set) Assessment, dated 4/15/11, indicated she was moderately cognitively impaired with a score of 12 out of 15. 2. The closed clinical record of Resident #D was reviewed on 7/12/11 at 10:45 A.M. and indicated [DIAGNOSES REDACTED]. During interview with Resident #D's daughter on 7/11/11 at 2:15 P.M., she indicated her mother had told her that a night CNA cussed at her, threw her in bed, and told her "I'm tired of you using that d--n call light. I'm tired of coming into your room. "My mother complained 'They're mean to me. They're mean to me.' I, at first, thought my mother was imagining it, but when the bruises and tremors were evident, I went to the DON with my concerns. I told her mother described the CNA as being a (race stated), tall woman. The DON said, 'We don't have a tall (race stated) girl working here.' My mother was lying in bed and looking up at the individual which probably made her look tall." In a second interview with Resident #D's daughter on 7/12/11 at 9:20 A.M., she indicated she asked her mother if she could remember the name of the CNA who was rough with her. "It was a (race stated) girl in the middle of the night." "She did complain to the DON (Name) about the treatment. We were very upset when the bruises were discovered at the hospital. Mother remembers them shoving her around and slamming her into bed and she told them, 'Be careful your going to break my hip, again.' " Review of Resident #D's initial MDS (Minimum Data Set) Assessment, dated 5/18/11, indicated she was cognitively intact with a score of 15 out of 15. During interview with the DON on 7/12/11 at 10:35 A.M., she indicated she was able to validate with the resident that the CNA was just hurrying. She further indicated, as a result, she did not feel there was a need to do a State Reportable. The Nursing staff schedule was reviewed and indicated CNA #15 was the only (race stated) CNA who provided care to Resident #D on the night shift. The May and June, 2011 schedules indicated CNA was assigned to provide care to Resident #D on the following dates: 5/24, 5/31, 6/7, 6/14, 6/18, and 6/19/11. CNA #15's Personnel File was reviewed on 7/12/11 at 4:15 P.M. and lacked documentation or any proof of investigation or reporting to State authorities the abuse allegations by Resident #D or her family. Resident #D's clinical record also lacked documentation of alleged abuse or investigation of any alleged abuse. 3. Resident #F's clinical record was reviewed on 7/13/11 at 4:00 P.M. and indicated [DIAGNOSES REDACTED]. During interview with CNA # 4 on 7/13/11 at 5:25 A.M., she indicated several residents have complained to her about CNA #15 being rough with them. When queried who those residents were, she indicated Resident #F and Resident #G. Her information lead to conducted interviews with both Resident #F and Resident #G. (However, Resident #F indicated it was CNA #2 who allegedly abused her.) Resident # F was identified as alert and oriented to person, place, and time by her physician in a History and Physical Report, dated 6/14/11, and by Social Service Staff #5 during an interview on 7/13/11 at 12:00 P.M. Resident #F's 14 day MDS (Minimum Data Set) Assessment, dated 6/17/11, indicted she was cognitively intact. She was admitted to the facility on [DATE] from an acute hospital. During interview with Resident #F on 7/13/11 at 9:15 A.M., she indicated that about 2 weeks ago, CNA #2 came into her room to assist her to the bathroom. CNA #2 insisted on putting Resident #F's back-brace on while she was sitting down. Resident #F told CNA #2 that Physical Therapist #6 told her she should be standing when the brace is put on her. CNA #2 responded, "I'll do it my way." Resident #F let her put the brace on while sitting because she was desperate to get to the bathroom. When she finished in the bathroom, CNA #2 assisted her to her bed. Resident #F, again, confronted CNA #2, this time regarding the position of the side rail on the bed. Resident #F informed CNA #2 that Physical Therapist #6 taught her to get into bed with the side rail down so she could position her body up higher on the mattress. CNA #2 replied in a snotty manner, "I'm not the therapist." Resident #F indicated she was sitting on the side of the bed when CNA #2 grabbed her by the sleeve and pulled her down toward the foot of the bed. "She then pushed my shoulders down on the bed, threw the pillow from my w/c onto the bed along with a sheet I used to cover my lap, and left me there. When she got angry her face got as red as an apple. I was afraid my back would get injured. I just had surgery and I don't want to have gone through all that pain for nothing. I'm just beginning to recover." Resident #F indicated she could not get anyone to help her, but when she saw CNA #3 outside her room she waved to her and she came to offer assistance. "She said, Oh dear, what happened to you? I told her what CNA #2 had done to me." Resident #F indicated CNA #3 had a physical condition which restricted her ability to lift, but together they managed to get her up in the bed. "She rescued me." When queried about the incident and what Resident #F was feeling at the time, she indicated she was fearful of CNA #2. .Resident #F indicated CNA #2 no longer provided her care, "I feel better that she isn't near me, but I would feel better if I didn't have to see her." Resident #F indicated she told the Director of Nursing (DON) the next day about CNA #2 and how she had frightened her. She indicated the DON was shocked and stated she had never had any problems with CNA #2 in the past. "She told me CNA #2 would not be assigned to take care of me again." She further indicated the DON told her if she filed a report there could be legal ramifications as a result. The DON indicated in an interview on 7/13/11 at 11:00 A.M. that she had not suspended CNA #2 because Resident #F did not mention to her that CNA #2 threw her into bed, but that she was bossy and put her into the bed and left her feet hanging off the bed. "Forty-five minutes later, when I sought clarification, Resident #F told me her feet were on the bed and she used her foot to get her call light." The DON further indicated CNA #2 was one of her best workers. During an interview with the DON on 7/13/11 at 2:30 P.M., evidence of an investigation of the incident between Resident #F and CNA #2 on 7/4/11 was requested from the DON. The DON indicated she would retrieve it from her office, but, just minutes later, the DON was observed interviewing LPN #7 regarding the incident that had been reported 8 days previously (7/5/11). The DON admitted she had not written up an investigation. When queried if she could produce any of the report, she produced a statement by CNA #2, dated 7/5/11. There was no other documentation which indicated suspension, investigation, reporting to State authorities, counseling, or disciplinary action had taken place. In her statement of 7/5/11, CNA #2 relayed a completely different story of the incident. CNA #2 indicated Resident #F wanted to go to the bathroom and get into bed, but she informed the resident that the nurse would like her to sit up in the recliner. "She told me to put down the side rail. I told her to let me show her how we transfer with the rail up, so she could grab it. I helped he (sic) into bed and lifted her legs into bed. She got mad at me for not putting down the side rail and asked to see the nurse." CNA #2 indicated she went to LPN #7 and told her two or three times that Resident #F wanted to see her, but LPN #7 was too busy. The DON was observed on 7/13/11 at 2:45 P.M., writing the statement Resident #F provided her on 7/5/11, but was unable to produce documentation to indicate other residents and staff had been interviewed as part of an investigation. During a telephone conversation on 7/13/11 at 2:50 P.M. with CNA #3, while in the presence of the DON and with the "speaker phone" on, CNA #3 indicated she found Resident #F sideways in her bed. She further indicated Resident #F told her CNA #2 "threw her into bed and left her there." CNA #3 and LPN #7 failed to report the incident to the DON, but Resident #F had voiced mistreatment to her on 7/5/11. 4. During interview with Resident #G on 7/13/11 at 10:35 A.M., she indicated she was fearful of using her call light because she had been yelled at by a staff person for having to go to the bathroom so much. "She would get angry when I had to go the bathroom. She was yelling 'Ever since they removed the catheter you've been a problem.' When someone knocks, I jump. I told them I was sorry, but I couldn't help it. Every time this need comes up (to use the bathroom) I get frightened. Recently, I had my light on, but no one came. I hurt because the pressure was so great. I took my blanket and folded it into a square and tucked it under me so I could pee on it without getting the rest of my bed wet. I reported that to (Social Service Staff #5) and the DON. Social Service Staff #5 indicated in an interview on 7/13/11 at 12:00 P.M. that he had been made aware of the situation and he met with Resident #G to discuss her feelings. He indicated this latest incident with the lack of a call light being answered happened on Monday, 7/11/11. "Resident #G has impaired vision and she was uncertain of the time, but she believed it was early morning around 5:00 A.M." During interview with the DON on 7/13/11 at 5:00 P.M., regarding the allegations made by Resident #G during interview with her on 7/13/11, she indicated she is still investigating the call light issue. Review of an "Internal Investigation" report, dated 4/15/11, it indicated, "Date of Occurrence: 4/2/11? or 4/3/11 Saturday night. Description of Occurrence: (Resident #G) c/o (complained of) a staff member complaining that she wants to go to the bathroom a lot and that her hands hurt after she grabbed her by the hands to take her into the bathroom...." A "Resident Statement" report, dated 4/4/11, indicated, "Sometimes I have vision and I can see...I think it was during the night or late evening. It was all about me having to go to the bathroom. This person was saying that I need to go to the bathroom all of the time. There was a time when I was. She said I had a problem. She was angry kind of. She said we need to do something about it...My hands are tender and she took me by the hands to take into the bathroom. They are sore...." A written statement by RN # 11, undated, indicated, "At 12 A (12:00 A.M.) 4/3/11, (Resident #G) began to tell me of an incident that she said happened last night. Attempted to clarify the time frame, but she was unsure. I gathered enough information to call in the morning to on call Supervisor. 7:45 A. M.-When I called LPN #12 (Supervisor), she call DON (Name) and requested a full statement and body check. Resident asked to tell what happened as it occurred. Resident (#G) didn't remember putting on call light, but someone came in, (Resident #G) said yelling at her. The following are statement contents and what she remembers. "You go (urinate) more than anyone I know." Resident (#G) said she needed to go to the bathroom. "I know this is all about going pee"...Someone grabbed her hands and was rough moving her around. "You need to do something about your bladder. You need to get your bladder checked. There is something wrong with you." Resident (#G) replied, "That may be true. (Resident #G) used the word 'forceful.' The person kept talking throughout the event to the bathroom and back. (Resident #G) said her face felt hot, and she was shaking all over...she said her hands hurt when they grabbed them...." The "Internal Investigation," dated "4/2/11 ? or 4/3/11", further indicated Resident G's son made the statement on 4/4/11, "I think this story about someone complaining about her going to the bathroom a lot comes from when she was first here. I know she is really sensitive when it comes to her arms and wrists...." Report "Conclusion: (Resident #G) suffers from confusion. Statements from staff are providing nothing conclusive. Her son seems to think that she is repeating an old idea...." A "Resident/Family Concern Report," dated 4/18/11 and signed by the DON, indicated, "Concerning Resident #G Nature of Concern: This writer noted resident coming down the hall in her wheelchair being pushed by (CNA #13), I asked (Resident #G) how she was doing. She said, 'Not very good right now.' Upon further questioning she complained that one of the CNA's complained that she was 'peeing' too much....I questioned (CNA #8), the other CNA in her room this afternoon. (CNA #8) said 'I didn't say that, I just took her to the bathroom." Explained to CNA (#8) that resident's many times have (sic) to urinate frequently for different reasons and that we can't judge this. We merely take them to the bathroom...Resolution and Disposition: "...CNA apologized to resident. A letter to the Indiana State Department of Health, dated 5/9/11, which included the Incident Report (regarding CNA #8 and another accusation by Resident #B) indicated, "...(CNA #8) was also involved on 4/18/11 in a complaint made by another resident, (Resident #G). She indicated that two CNA's complained that she urinated too frequently. One of these CNA's was (CNA #8)...." Resident #G's clinical record and the Personnel Record of CNA #8, lacked documentation that the 4/2/11 and the 4/18/11 complaint of alleged abuse by Resident #G was reported to State authorities. It was briefly mentioned (21 days later) in the above letter and incident report, dated 5/9/11. Review of Resident #G's clinical record on 7//13/11 at 10:00 A.M., indicated [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] from an acute hospital. A quarterly MDS (Minimum Data Set) Assessment, dated 6/31/11, indicated Resident #G's vision was severely impaired, was occasionally incontinent of urine and needed limited assistance of one for toileting. The Administrator indicated in an interview on 4/14/11 at 4:00 P.M., she was unaware of the abuse allegations. "The Director of Nursing has always addressed those issues. The previous DON did the same thing." Review of a facility policy titled "Primary Abuse Prohibition Policy," dated 9/2000, indicated, "Policy: It shall be the policy of Southfield Village that all residents of this facility are free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion...Policy/Procedure Definitions: ...1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Also includes, Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psycho-social well being. 2. Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance...(Examples: threats of harm, saying things to frighten a resident...4. Physical Abuse: Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 5. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment of deprivation...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...Abuse-Identification of...Procedure: 1. ...staff and supervisory personnel will be cognizant of the potential for abuse of residents...2. The Administrator will be responsible for monitoring quality assurance and quality improvement progress reports for patterns, occurrences and trends that would be suggestive of abuse, neglect, ...within the facility. 3. The Administrator will be responsible for monitoring incident/accident reports for potential abuse...Investigation...Procedure: ...3. Staff incidents which involve abuse, neglect, ...are investigated as follows: 3.1 The staff member is suspended immediately without pay pending investigation. It is the intent of the facility to finalize an investigation within 3-5 days...." The immediate jeopardy that began on 7/5/11 was removed on 7/15/11 when the facility suspended the staff accused of alleged abuse and began investigations, began immediate mandatory in-services on proper protocols to follow regarding abuse and neglect, reviewed facility's abuse policy and procedure and found it to be reasonable and accurate, met with all management staff and on-call nursing staff to review protocol for reporting abuse, revised the daily stand-up meeting form to include allegations of abuse and neglect, notified the facility Medical Director of the immediate jeopardy, posted phone numbers of the Administrator and Director of Nursing in multiple locations of the facility with instructions to immediately report any allegation of abuse at any time, ensured the Administrator or her designee will monitor abuse protocol by randomly interviewing five residents per week for no less than six months, and ensured the facility will continue to provide abuse and neglect education upon hire and at least twice annually, but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure staff continued to recognize and report abuse and monitor staff to ensure they continued to follow the corrective action plan. This Federal tag relates to complaint IN 132. 3.1-28(a)

Based on interview and record review, the Administrative Staff failed to ensure Residents in the facility were protected from physical and verbal abuse by failing to follow their policy and procedures for reporting, investigating, monitoring, and documenting related to failure to suspend accused staff, investigate and document abuse allegations, and monitor for patterns and occurrences of alleged abuse for 2 of 4 residents (Resident: #B, #D) in the sample of 4 and 2 of 6 residents (Residents: #F, #G) in the supplemental sample of 6. This deficient practice had the potential to affect all 60 of 60 residents residing in the facility. The immediate jeopardy began on 7/05/11 when Resident # F, who was recovering from recent back surgery, reported to CNA #3 on 7/4/11 that CNA #2 had thrown her into bed and left her sideways in the bed. Resident # F then reported the incident on 7/5/11 to the Director of Nursing who failed to suspend CNA #2 and protect other residents from potential harm during investigation of the alleged abuse. The Administrator and the Director of Nursing (DON) were notified of the immediate jeopardy at 5:30 P.M. on 7/13/11. The immediate jeopardy was: removed on 7/15/11, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Residents: #B, #C, #D, #F, #G Findings include: 1. A"Resident/Family Concern Report," dated 5/3/11, and signed by the Chaplain, indicated, "Nature of Concern: Resident (#B) reported rough handling and bad attitude of CNA #8 when resident asked repeatedly for bed pan last week. Resident #B thought she had asked 'someone in charge' to not have this CNA (#8) help with her care. Last evening, 5/2/11, (CNA #8) came to do (Resident #B's) shower. (Resident #8) reported she was sprayed in the face, and (CNA #8) was not following her wishes concerning (Resident #B's) clothing...." An "Investigation" report, dated 5/4/11 and signed by RN #9, indicated, "...The previous week Nurse (LPN #10) had called (Name), DON re: (regarding) a conflict between (Resident #B) and (CNA #8). (Resident #B) did not want (CNA #8) in her room. I was working Wing 200 that nite (sic) and overheard the phone conversation at the nurses station on Wed., April 27th." During interview with the DON on 7/12/11 at 2:30 P.M., she indicated she was unaware Resident #B requested CNA #8 not be assigned to provide her care. Review of CNA's Personnel File on 7/11/11 at 3:20 P.M. lacked documentation of an investigation, a State reportable, counseling, or disciplinary action regarding the issue reported by LPN #10 regarding Resident #B's accusation of alleged rough handling by CNA #8 when assisting her with the bedpan (4/27/11). 2. During interview with Resident #D's daughter on 7/11/11 at 2:15 P.M., she indicated her mother had told her that a night CNA cussed at her, threw her in bed, and told her "I'm tired of you using that d--n call light. I'm tired of coming into your room. "My mother complained 'They're mean to me. They're mean to me.' I, at first, thought my mother was imagining it, but when the bruises and tremors were evident, I went to the DON with my concerns. I told her mother described the CNA as being a (race stated), tall woman. The DON said, 'We don't have a tall (race stated) girl working here.' My mother was lying in bed and looking up at the individual which probably made her look tall." In a second interview with Resident #D's daughter on 7/12/11 at 9:20 A.M., she indicated she asked her mother if she could remember the name of the CNA who was rough with her. "It was a (race stated) girl in the middle of the night." "She did complain to the DON (Name) about the treatment. We were very upset when the bruises were discovered at the hospital. Mother remembers them shoving her around and slamming her into bed and she told them, 'Be careful your going to break my hip, again.' " During interview with the DON on 7/12/11 at 10:35 A.M., she indicated she was able to validate with the resident that the CNA was just hurrying. She further indicated, as a result, she did not feel there was a need to do a State Reportable. The Nursing staff schedule was reviewed and indicated CNA #15 was the only (race stated) CNA who provided care to Resident #D on the night shift. The May and June, 2011 schedules indicated CNA was assigned to provide care to Resident #D on the following dates: 5/24, 5/31, 6/7, 6/14, 6/18, and 6/19/11. CNA #15's Personnel File was reviewed on 7/12/11 at 4:15 P.M. and lacked documentation or any proof of investigation regarding Resident #D or her family's alleged abuse by CNA #15. 3. During interview with Resident #F on 7/13/11 at 9:15 A.M., she indicated that about 2 weeks ago, CNA #2 came into her room to assist her to the bathroom. CNA #2 insisted on putting Resident #F's back-brace on while she was sitting down. Resident #F told CNA #2 that Physical Therapist #6 told her she should be standing when the brace is put on her. CNA #2 responded, "I'll do it my way." Resident #F let her put the brace on while sitting because she was desperate to get to the bathroom. When she finished in the bathroom, CNA #2 assisted her to her bed. Resident #F, again, confronted CNA #2, this time regarding the position of the side rail on the bed. Resident #F informed CNA #2 that Physical Therapist #6 taught her to get into bed with the side rail down so she could position her body up higher on the mattress. CNA #2 replied in a snotty manner, "I'm not the therapist." Resident #F indicated she was sitting on the side of the bed when CNA #2 grabbed her by the sleeve and pulled her down toward the foot of the bed. "She then pushed my shoulders down on the bed, threw the pillow from my w/c onto the bed along with a sheet I used to cover my lap, and left me there. When she got angry her face got as red as an apple. I was afraid my back would get injured. I just had surgery and I don't want to have gone through all that pain for nothing. I'm just beginning to recover." Resident #F indicated she could not get anyone to help her, but when she saw CNA #3 outside her room she waved to her and she came to offer assistance. "She said, Oh dear, what happened to you? I told her what CNA #2 had done to me." Resident #F indicated CNA #3 had a physical condition which restricted her ability to lift, but together they managed to get her up in the bed. "She rescued me." When queried about the incident and what Resident #F was feeling at the time, she indicated she was fearful of CNA #2. .Resident #F indicated CNA #2 no longer provided her care, "I feel better that she isn't near me, but I would feel better if I didn't have to see her." Resident #F indicated she told the Director of Nursing (DON) the next day about CNA #2 and how she had frightened her. She indicated the DON was shocked and stated she had never had any problems with CNA #2 in the past. "She told me CNA #2 would not be assigned to take care of me again." She further indicated the DON told her if she filed a report there could be legal ramifications as a result. The DON indicated in an interview on 7/13/11 at 11:00 A.M. that she had not suspended CNA #2 because Resident #F did not mention to her that CNA #2 threw her into bed, but that she was bossy and put her into the bed and left her feet hanging off the bed. "Forty-five minutes later, when I sought clarification, Resident #F told me her feet were on the bed and she used her foot to get her call light." The DON further indicated CNA #2 was one of her best workers. During a telephone conversation on 7/13/11 at 2:50 P.M. with CNA #3, while in the presence of the DON and with the "speaker phone" on, CNA #3 indicated she found Resident #F sideways in her bed. She further indicated Resident #F told her CNA #2 "threw her into bed and left her there." CNA #3 and LPN #7 failed to report the incident to the DON, but Resident #F had voiced mistreatment to her on 7/5/11. Resident #F's clinical record lacked documentation of an investigation, a State Reportable, counseling, or disciplinary action regarding the issue reported to the DON on 7/5/11 by Resident #F. 4. During interview with Resident #G on 7/13/11 at 10:35 A.M., she indicated she was fearful of using her call light because she had been yelled at by a staff person for having to go to the bathroom so much. "She would get angry when I had to go the bathroom. She was yelling 'Ever since they removed the catheter you've been a problem.' When someone knocks, I jump. I told them I was sorry, but I couldn't help it. Every time this need comes up (to use the bathroom) I get frightened. Recently, I had my light on, but no one came. I hurt because the pressure was so great. I took my blanket and folded it into a square and tucked it under me so I could pee on it without getting the rest of my bed wet. I reported that to (Social Service Staff #5) and the DON. Review of an "Internal Investigation" report, dated 4/15/11, indicated, "Date of Occurrence: 4/2/11? or 4/3/11 Saturday night. Description of Occurrence: (Resident #G) c/o (complained of) a staff member complaining that she wants to go to the bathroom a lot and that her hands hurt after she grabbed her by the hands to take her into the bathroom...." A "Resident Statement" report, dated 4/4/11, indicated, "Sometimes I have vision and I can see...I think it was during the night or late evening. It was all about me having to go to the bathroom. This person was saying that I need to go to the bathroom all of the time. There was a time when I was. She said I had a problem. She was angry kind of. She said we need to do something about it...My hands are tender and she took me by the hands to take into the bathroom. They are sore...." A written statement by RN # 11, undated, indicated, "At 12 A (12:00 A.M.) 4/3/11, (Resident #G) began to tell me of an incident that she said happened last night. Attempted to clarify the time frame, but she was unsure. I gathered enough information to call in the morning to on call Supervisor. 7:45 A. M.-When I called LPN #12 (Supervisor), she called DON (Name) and requested a full statement and body check. Resident asked to tell what happened as it occurred. Resident (#G) didn't remember putting on call light, but someone came in, (Resident #G) said yelling at her. The following are statement contents and what she remembers. "You go (urinate) more than anyone I know." Resident (#G) said she needed to go to the bathroom. "I know this is all about going pee"...Someone grabbed her hands and was rough moving her around. "You need to do something about your bladder. You need to get your bladder checked. There is something wrong with you." Resident (#G) replied, "That may be true. (Resident #G) used the word 'forceful.' The person kept talking throughout the event to the bathroom and back. (Resident #G) said her face felt hot, and she was shaking all over...she said her hands hurt when they grabbed them...." The "Internal Investigation" further indicated Resident G's son made the statement, "I think this story about someone complaining about her going to the bathroom a lot comes from when she was first here. I know she is really sensitive when it comes to her arms and wrists...." Report "Conclusion: (Resident #G) suffers from confusion. Statements from staff are providing nothing conclusive. Her son seems to think that she is repeating an old idea...." A "Resident/Family Concern Report," dated 4/18/11 and signed by the DON, indicated, "Concerning Resident #G Nature of Concern: This writer noted resident coming down the hall in her wheelchair being pushed by (CNA #13), I asked (Resident #G) how she was doing. She said, 'Not very good right now.' Upon further questioning she complained that one of the CNA's complained that she was 'peeing' too much....I questioned (CNA #8), the other CNA in her room this afternoon. (CNA #8) said 'I didn't say that, I just took her to the bathroom." Explained to CNA (#8) that resident's many times have (sic) to urinate frequently for different reasons and that we can't judge this. We merely take them to the bathroom...Resolution and Disposition: "...CNA apologized to resident. A letter to the Indiana State Department of Health, dated 5/9/11, which included the Incident Report (regarding CNA #8 and another accusation by Resident #B) indicated, "...(CNA #8) was also involved on 4/18/11 in a complaint made by another resident, (Resident #G). She indicated that two CNA's complained that she urinated too frequently. One of these CNA's was (CNA #8)...." Resident #G's clinical record and the Personnel File of CNA #8, lacked documentation that the 4/2/11 and the 4/18/11 complaint of alleged abuse by Resident #G were reported to State authorities. During an interview with the Administrator on 4/14/11 at 4:00 P.M., she indicated she was unaware of the abuse allegations. "The Director of Nursing has always addressed those issues. The previous DON did the same thing." Review of a facility policy titled "Primary Abuse Prohibition Policy," dated 9/2000, indicated, "Policy: It shall be the policy of Southfield Village that all residents of this facility are free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion...The Administrator will be responsible for monitoring quality assurance and quality improvement progress reports for patterns, occurrences and trends that would be suggestive of abuse, neglect, ...within the facility. 3. The Administrator will be responsible for monitoring incident/accident reports for potential abuse...Investigation...Procedure: ...3. Staff incidents which involve abuse, neglect, ...are investigated as follows: 3.1 The staff member is suspended immediately without pay pending investigation. It is the intent of the facility to finalize an investigation within 3-5 days...." The immediate jeopardy that began on 7/5/11 was removed on 7/15/11 when the facility suspended the staff accused of alleged abuse and began investigations, began immediate mandatory in-services on proper protocols to follow regarding abuse and neglect, reviewed facility's abuse policy and procedure and found it to be reasonable and accurate, met with all management staff and on-call nursing staff to review protocol for reporting abuse, revised the daily stand-up meeting form to include allegations of abuse and neglect, notified the facility Medical Director of the immediate jeopardy, posted phone numbers of the Administrator and Director of Nursing in multiple locations of the facility with instructions to immediately report any allegation of abuse at any time, ensured the Administrator or her designee will monitor abuse protocol by randomly interviewing five residents per week for no less than six months, and ensured the facility will continue to provide abuse and neglect education upon hire and at least twice annually, but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure staff continued to recognize and report abuse and monitor staff to ensure they continued to follow the corrective action plan. This Federal tag relates to complaint IN 132. 3.1-13(a)

Based on observations, interviews and record reviews, the facility failed to protect residents from physical and verbal abuse by facility staff which resulted in psychological harm and mental anguish as evidenced by residents' fear to summon staff for assistance or provision of their care for 3 of 4 residents (Residents: #B, #C, #D) reviewed for abuse in a sample of 4 and 2 of 6 residents (Residents: #F, #G) in the supplemental sample of 6. The immediate jeopardy began on 7/05/11 when Resident # F, who was recovering from recent back surgery, reported to CNA #3 on 7/4/11 that CNA #2 had thrown her into bed and left her sideways in the bed. Resident # F then reported the incident on 7/5/11 to the Director of Nursing who failed to suspend CNA #2 and protect other residents from potential harm during investigation of the alleged abuse. The Administrator and the Director of Nursing (DON) were notified of the immediate jeopardy at 5:30 P.M. on 7/13/11. The immediate jeopardy was: removed on 7/15/11, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Residents: #B, #C, #D, #F, #G Findings include: 1. Review of a facility "Incident Report," dated 5/3/11, indicated, "...(Resident #B) alleges that on Monday, 5-2-11, a CNA who gave her a shower treated her roughly and had a "bad attitude." She reported that she was sprayed in the face with the shower sprayer...." A"Resident/Family Concern Report," dated 5/3/11, and signed by the Chaplain, indicated, "Nature of Concern: Resident (#B) reported rough handling and bad attitude of CNA #8 when resident asked repeatedly for bed pan last week. Resident #B thought she had asked 'someone in charge' to not have this CNA (#8) help with her care. Last evening, 5/2/11, (CNA #8) came to do (Resident #B's) shower. (Resident #8) reported she was sprayed in the face, and (CNA #8) was not following her wishes concerning (Resident #B's) clothing...." During interview with the DON on 7/12/11 at 2:30 P.M., she indicated she was unaware Resident #B requested CNA #8 not be assigned to provide her care. An "Investigation" report, dated 5/4/11 and signed by RN #9, indicated, "On Monday, May 2nd, approx (approximately) 9:00 P.M., I entered (Resident #B's) (room number) with her H.S. (bedtime) meds (medications). (CNA #8) had just showered her. (Resident #B) said to me: 'I don't know what is wrong with that girl. I don't like the way she handles me. When I saw her face I knew I was in for it'...The previous week Nurse (LPN #10) had called (Name), DON re: (regarding) a conflict between (Resident #B) and (CNA #8). (Resident #B) did not want (CNA #8) in her room. I was working Wing 200 that nite (sic) and overheard the phone conversation at the nurses station on Wed., April 27th." Review of the "CNA Evening Assignment," dated 5/2/11, indicated CNA #8 had been assigned to (Resident #B's) room. Review of CNA's Employee Record on 7/11/11 at 3:20 P.M. lacked documentation of an investigation, counseling, or disciplinary action regarding the issue reported by LPN #10 regarding Resident #B's accusation of alleged rough handling by CNA #8 when assisting her with the bedpan (4/27/11). An "Employee Counseling Form," dated 5/3/11, indicated CNA #8 was suspended 5/3/11 pending investigation. The DON indicated in the interview on 7/12/11 at 2:30 P.M. that CNA #8 had been terminated on 5/9/11. Resident #B's closed clinical record was reviewed on 7/11/11 at 3:45 P.M., and indicated [DIAGNOSES REDACTED]. An initial MDS (Minimum Data Set) Assessment, dated 4/15/11, indicated she was moderately cognitively impaired with a score of 12 out of 15. 2. Resident #C's clinical record was reviewed on 7/11/11 at 11:55 P.M. and indicated [DIAGNOSES REDACTED]. Resident #C's initial MDS (minimum Data Set) Assessment, dated 3/17/11, indicated she was cognitively intact with a score of 15 out of 15. Review of an "Incident Report," dated 3/14/11, indicated, "...(Resident #C) told this writer today at 3:00 P.M. about a problem that she had on Saturday, 3/12/11. She states that (CNA #18) on Saturday 'went all crazy. She started pulling my bed and moving stuff around. She was loud and had me so upset I couldn't half talk. She was swinging my leg around so fast.' I asked if anyone had hurt her or yelled at her. She said no, but she was scared...." A "Resident Statement," dated 3/14/11, was the result of a conversation with the DON and indicated, "...You know I don't know what she (CNA #18) went crazy about. The other lady (CNA #2) looked like she was scared of her. She was movin stuff around, the bed was facing the closet. I said, 'I can't have that way.' She had me so upset I couldn't half talk. Someway I got to the phone and called my daughter...She (CNA #18) was swinging my leg around so fast, too...I been having so much pain in that leg...." During interview with Resident #C on 7/12/11 at 9:20 A.M., she indicated, "I needed to go to the bathroom. Two CNA's came in to assist me when the one girl (CNA #18) went crazy because she needed more room to get me on the commode (bedside). I was so frightened I couldn't talk and I was having trouble breathing. A third girl came into the room. At one point, they all went into my bathroom and closed the door. I don't know what they were talking about in there. When they got me back into bed, I was facing the wall. I didn't want to face the wall, I wanted to be able to see out my window. The one girl (CNA #18) was slamming things around and shouting. I didn't know what she was going to do next. I was so scared of her. I managed to call my daughter to tell her, but it so happened my son was coming to visit. He said he could hear me calling for help all the way down the hall." During a telephone interview with CNA #2, the other CNA in the room, at the time of the incident, indicated CNA #18 was assigned to Resident #C on the day of the incident, but she (CNA #2) took care of her all day "because I knew how (CNA # 18) could be. I knew (CNA #18) was a very forward type of person and that back section was very heavy and she's (CNA #18) kinda bossy." She further indicated they told Resident #C they would have to move the furniture around and she was fine with that "do what ever you need to do." "Resident #C threw her arms up in the air almost like she was praying. I asked her if she needed her oxygen because of the way she was acting." When queried if CNA #18 acted appropriately, CNA #2 stated, "I felt that she did everything excessively. She should have explained things first. (CNA #18) was not abusive in any way (but) she was almost like a drill sergeant. Some residents thought she was a man." The DON indicated in an interview on 7/11/11 at 1:30 P.M., she didn't feel she could substantiate that abuse took place, but felt since she had other issues with both of the CNA's (#2 and #18) "It warranted termination." 3. The closed clinical record of Resident #D was reviewed on 7/12/11 at 10:45 A.M. and indicated [DIAGNOSES REDACTED]. Resident #D's initial MDS (Minimum Data Set) Assessment, dated 5/18/11, indicated she was cognitively intact with a score of 15 out of 15. During interview with Resident #D's daughter on 7/11/11 at 2:15 P.M., she indicated her mother had told her that a night CNA cussed at her, threw her in bed, and told her "I'm tired of you using that d--n call light. I'm tired of coming into your room. "My mother complained 'They're mean to me. They're mean to me.' I, at first, thought my mother was imagining it, but when the bruises and tremors were evident, I went to the DON with my concerns. I told her mother described the CNA as being (race stated), tall woman. The DON said, 'We don't have a tall (race stated) girl working here.' My mother was lying in bed and looking up at the individual which probably made her look tall." In a second interview with Resident #D's daughter on 7/12/11 at 9:20 A.M., she indicated she asked her mother if she could remember the name of the CNA who was rough with her. "It was a (race stated) girl in the middle of the night." "She did complain to the DON (Name) about the treatment. We were very upset when the bruises were discovered at the hospital. Mother remembers them shoving her around and slamming her into bed and she told them, 'Be careful your going to break my hip, again.' " During interview with the DON on 7/12/11 at 10:35 A.M., she indicated she was able to validate with the resident that the CNA was just hurrying. She further indicated, as a result, she did not feel there was a need to do a State Reportable. The Nursing staff schedule was reviewed and indicated CNA #15 was the only (race stated) CNA who provided care to Resident #D on the night shift. The May and June, 2011 schedules indicated CNA #15 was assigned to provide care to Resident #D on the following dates: 5/24, 5/31, 6/7, 6/14, 6/18, and 6/19/11. During interview with CNA #14 on 5/13/11 at 5:50 A.M., she indicated residents frequently complained to her about a particular CNA refusing to toilet a resident. "I overheard (CNA #15) being rude to a resident. I heard her tell the resident, 'I can't take you to the bathroom again. You just went 10 minutes ago.' Three or four of us girls have gone to the nurse's, but nothing seems to be done about it." LPN #16 indicated in an interview on 5/13/11 at 5:45 A.M., "One night (CNA #15) came to me and told me she was tired of answering (Resident #G's) call light and I would have to do it. (CNA #15) said, 'She's getting on my nerves.' " When queried if she reported it to the Supervisor she stated, "No, but I talked about it with the other nurse." During interview with CNA #17 on 7/13/11 at 5:50 A.M., she indicated a resident complained to her that she was left in bed. CNA #15 would not take her to the bathroom when she needed to go. "She wasn't soiled, but she really gushed when I took her." 4. Resident #F's clinical record was reviewed on 7/13/11 at 4:00 P.M. and indicated [DIAGNOSES REDACTED]. During interview with CNA #4 on 7/13/11 at 5:25 A.M., she indicated several residents have complained to her about CNA #15 being rough with them. When queried who those residents were, she indicated Resident #F and Resident #G. Her information lead to conducted interviews with both Resident #F and Resident #G. (However, Resident #F indicated in the interview on 7/13/11 that it was CNA #2 who allegedly abused her.) Resident # F was identified as alert and oriented to person, place, and time by her physician in a History and Physical Report, dated 6/14/11, and by Social Service Staff #5 during an interview on 7/13/11 at 12:00 P.M. Resident #F's 14 day MDS (Minimum Data Set) Assessment, dated 6/17/11, indicted she was cognitively intact. She was admitted to the facility on [DATE] from an acute hospital. During interview with Resident #F on 7/13/11 at 9:15 A.M., she indicated that about 2 weeks ago, CNA #2 came into her room to assist her to the bathroom. CNA #2 insisted on putting Resident #F's back-brace on while she was sitting down. Resident #F told CNA #2 that Physical Therapist #6 told her she should be standing when the brace is put on her. CNA #2 responded, "I'll do it my way." Resident #F let her put the brace on while sitting because she was desperate to get to the bathroom. When she finished in the bathroom, CNA #2 assisted her to her bed. Resident #F, again, confronted CNA #2, this time regarding the position of the side rail on the bed. Resident #F informed CNA #2 that Physical Therapist #6 taught her to get into bed with the side rail down so she could position her body up higher on the mattress. CNA #2 replied in a snotty manner, "I'm not the therapist." Resident #F indicated she was sitting on the side of the bed when CNA #2 grabbed her by the sleeve and pulled her down toward the foot of the bed. "She then pushed my shoulders down on the bed, threw the pillow from my w/c onto the bed along with a sheet I used to cover my lap, and left me there. When she got angry her face got as red as an apple. I was afraid my back would get injured. I just had surgery and I don't want to have gone through all that pain for nothing. I'm just beginning to recover." Resident #F indicated she could not get anyone to help her, but when she saw CNA #3 outside her room she waved to her and she came to offer assistance. "She said, Oh dear, what happened to you? I told her what CNA #2 had done to me." Resident #F indicated CNA #3 had a physical condition which restricted her ability to lift, but together they managed to get her up in the bed. "She rescued me." When queried about the incident and what Resident #F was feeling at the time, she indicated she was fearful of CNA #2. .Resident #F indicated CNA #2 no longer provided her care, "I feel better that she isn't near me, but I would feel better if I didn't have to see her." Resident #F indicated she told the Director of Nursing (DON) the next day about CNA #2 and how she had frightened her. She indicated the DON was shocked and stated she had never had any problems with CNA #2 in the past. "She told me CNA #2 would not be assigned to take care of me again." She further indicated the DON told her if she filed a report there could be legal ramifications as a result. The DON indicated in an interview on 7/13/11 at 11:00 A.M. that she had not suspended CNA #2 because Resident #F did not mention to her that CNA #2 threw her into bed, but that she was bossy and put her into the bed and left her feet hanging off the bed. "Forty-five minutes later, when I sought clarification, Resident #F told me her feet were on the bed and she used her foot to get her call light." The DON further indicated CNA #2 was one of her best workers. During an interview with the DON on 7/13/11 at 2:30 P.M., evidence of an investigation of the incident between Resident #F and CNA #2 on 7/4/11 was requested from the DON. The DON indicated she would retrieve it from her office but, just minutes later, the DON was observed interviewing LPN #7 regarding the incident that had been reported 8 days previously (7/5/11). The DON admitted she had not written up an investigation. When queried if she could produce any of the report, she produced a statement by CNA #2, dated 7/5/11, in which she relayed a completely different story of the incident. In her written statement, CNA #2 indicated Resident #F wanted to go to the bathroom and get into bed, but she informed the resident that the nurse would like her to sit up in the recliner. "She told me to put down the side rail. I told her to let me show her how we transfer with the rail up, so she could grab it. I helped he (sic) into bed and lifted her legs into bed. She got mad at me for not putting down the side rail and asked to see the nurse." CNA #2 indicated she went to LPN #7 and told her two or three times that Resident #F wanted to see her, but LPN #7 was too busy. The DON was observed on 7/13/11 at 2:45 P.M., writing the statement Resident #F provided her on 7/5/11, but was unable to produce documentation to indicate other residents and staff had been interviewed as part of an investigation. During a telephone conversation on 7/13/11 at 2:50 P.M. with CNA #3, while in the presence of the DON and with the "speaker phone" on, CNA #3 indicated she found Resident #F sideways in her bed. She further indicated Resident #F told her CNA #2 "threw her into bed and left her there." CNA #3 and LPN #7 failed to report the incident to the DON, but Resident #F had voiced mistreatment to her on 7/5/11. 5. During interview with Resident #G on 7/13/11 at 10:35 A.M., she indicated she was fearful of using her call light because she had been yelled at by a staff person for having to go to the bathroom so much. "She would get angry when I had to go the bathroom. She was yelling 'Ever since they removed the catheter you've been a problem.' When someone knocks, I jump. I told them I was sorry, but I couldn't help it. Every time this need comes up (to use the bathroom) I get frightened. Recently, I had my light on, but no one came. I hurt because the pressure was so great. I took my blanket and folded it into a square and tucked it under me so I could pee on it without getting the rest of my bed wet. I reported that to (Social Service Staff #5) and the DON. Social Service Staff #5 indicated in an interview on 7/13/11 at 12:00 P.M. that he had been made aware of the situation and he met with Resident #G to discuss her feelings. He indicated this latest incident with the lack of a call light being answered happened on Monday, 7/11/11. "Resident #G has impaired vision and she was uncertain of the time, but she believed it was early morning around 5:00 A.M." During interview with the DON on 7/13/11 at 5:00 P.M., regarding the allegations made by Resident #G during interview with her on 7/13/11, she indicated she is still investigating the call light issue. Review of an "Internal Investigation" report, dated 4/15/11, it indicated, "Date of Occurrence: 4/2/11? or 4/3/11 Saturday night. Description of Occurrence: (Resident #G) c/o (complained of) a staff member complaining that she wants to go to the bathroom a lot and that her hands hurt after she grabbed her by the hands to take her into the bathroom...." A "Resident Statement" report, dated 4/4/11, indicated, "Sometimes I have vision and I can see...I think it was during the night or late evening. It was all about me having to go to the bathroom. This person was saying that I need to go to the bathroom all of the time. There was a time when I was. She said I had a problem. She was angry kind of. She said we need to do something about it...My hands are tender and she took me by the hands to take into the bathroom. They are sore...." A written statement by RN # 11, undated, indicated, "At 12 A (12:00 A.M.) 4/3/11, (Resident #G) began to tell me of an incident that she said happened last night. Attempted to clarify the time frame, but she was unsure. I gathered enough information to call in the morning to on call Supervisor. 7:45 A. M.-When I called LPN #12 (Supervisor), she called DON (Name) and requested a full statement and body check. Resident asked to tell what happened as it occurred. Resident (#G) didn't remember putting on call light, but someone came in, (Resident #G) said yelling at her. The following are statement contents and what she remembers. "You go (urinate) more than anyone I know." Resident (#G) said she needed to go to the bathroom. "I know this is all about going pee"...Someone grabbed her hands and was rough moving her around. "You need to do something about your bladder. You need to get your bladder checked. There is something wrong with you." Resident (#G) replied, "That may be true. (Resident #G) used the word 'forceful.' The person kept talking throughout the event to the bathroom and back. (Resident #G) said her face felt hot, and she was shaking all over...she said her hands hurt when they grabbed them...." The "Internal Investigation" further indicated Resident G's son made the statement, "I think this story about someone complaining about her going to the bathroom a lot comes from when she was first here. I know she is really sensitive when it comes to her arms and wrists...." Report "Conclusion: (Resident #G) suffers from confusion. Statements from staff are providing nothing conclusive. Her son seems to think that she is repeating an old idea...." A "Resident/Family Concern Report," dated 4/18/11 and signed by the DON, indicated, "Concerning Resident #G Nature of Concern: This writer noted resident coming down the hall in her wheelchair being pushed by (CNA #13), I asked (Resident #G) how she was doing. She said, 'Not very good right now.' Upon further questioning she complained that one of the CNA's complained that she was 'peeing' too much....I questioned (CNA #8), the other CNA in her room this afternoon. (CNA #8) said 'I didn't say that, I just took her to the bathroom." Explained to CNA (#8) that resident's many times have (sic) to urinate frequently for different reasons and that we can't judge this. We merely take them to the bathroom...Resolution and Disposition: "...CNA apologized to resident. A letter to the Indiana State Department of Health, dated 5/9/11, which included the Incident Report (regarding CNA #8 and another accusation by Resident #B) indicated, "...(CNA #8) was also involved on 4/18/11 in a complaint made by another resident, (Resident #G). She indicated that two CNA's complained that she urinated too frequently. One of these CNA's was (CNA #8)...." Review of Resident #G's clinical record on 7//13/11 at 10:00 A.M., indicated [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] from an acute hospital. A quarterly MDS (Minimum Data Set) Assessment, dated 6/31/11, indicated Resident #G's vision was severely impaired, was occasionally incontinent of urine and needed limited assistance of one for toileting. During interview with CNA #14 on 5/13/11 at 5:50 A.M., she indicated residents frequently complain to her about a particular CNA refusing to toilet a resident. "I overheard (CNA #15) being rude to a resident. I heard her tell the resident, 'I can't take you to the bathroom again. You just went 10 minutes ago.' Three or four of us girls have gone to the nurses, but nothing seems to be done about it." LPN #16 indicated in an interview on 5/13/11 at 5:45 A.M., "One night (CNA #15) came to me and told me she was tired of answering (Resident #G's) call light and I would have to do it. (CNA #15) said, 'She's getting on my nerves.' " When queried if she reported it to the Supervisor she stated, "No, but I talked about it with the other nurse." During interview with CNA #17 on 7/13/11 at 5:50 A.M., she indicated a resident complained to her that she was left in bed. CNA #15 would not take her to the bathroom when she needed to go. "She wasn't soiled, but she really gushed when I took her." Review of a facility policy titled "Primary Abuse Prohibition Policy," dated 9/2000, indicated, "Policy: It shall be the policy of Southfield Village that all residents of this facility are free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion...Policy/Procedure Definitions: ...1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Also includes, Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psycho-social well being. 2. Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance...(Examples: threats of harm, saying things to frighten a resident...4. Physical Abuse: Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 5. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment of deprivation...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...Abuse-Identification of...Procedure: 1. ...staff and supervisory personnel will be cognizant of the potential for abuse of residents...2. The Administrator will be responsible for monitoring quality assurance and quality improvement progress reports for patterns, occurrences and trends that would be suggestive of abuse, neglect, ...within the facility. 3. The Administrator will be responsible for monitoring incident/accident reports for potential abuse...Investigation...Procedure: ...3. Staff incidents which involve abuse, neglect, ...are investigated as follows: 3.1 The staff member is suspended immediately without pay pending investigation. It is the intent of the facility to finalize an investigation within 3-5 days...." The immediate jeopardy that began on 7/5/11 was removed on 7/15/11 when the facility suspended the staff accused of alleged abuse and began investigations, began immediate mandatory in-services on proper protocols to follow regarding abuse and neglect, reviewed facility's abuse policy and procedure and found it to be reasonable and accurate, met with all management staff and on-call nursing staff to review protocol for reporting abuse, revised the daily stand-up meeting form to include allegations of abuse and neglect, notified the facility Medical Director of the immediate jeopardy, posted phone numbers of the Administrator and Director of Nursing in multiple locations of the facility with instructions to immediately report any allegation of abuse at any time, ensured the Administrator or her designee will monitor abuse protocol by randomly interviewing five residents per week for no less than six months, and ensured the facility will continue to provide abuse and neglect education upon hire and at least twice annually, but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure staff continued to recognize and report abuse and monitor staff to ensure they continued to follow the corrective action plan. This Federal tag relates to complaint IN 132. 3.1-27(a)(1) 3-1.27(b)