Every finding on record at The Green House Cottages of Southern Hills

Number of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to ensure a resident’s wheelchair was properly secured to ensure the resident was safely transported in the facility van for one (Resident #4) of one resident reviewed. The findings include: A review of a Police Incident Report Form indicated that near an address between [town name] and the facility, Certified Nursing Assistant (CNA) #1 was driving the van with two passengers inside: the Activities Director (AD) and Resident #4. While traveling, the wheelchair Resident #4 was seated in suddenly rolled backwards. This caused Resident #4 to bump the back of their head. The resident was transported to the emergency room for evaluation and treatment. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/04/2025, revealed Resident #4 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated the resident had diagnoses which included fracture of unspecified part of thigh bone, worn cartilage of the joints, anxiety, diabetes mellitus, and muscle wasting and shrinkage. Resident #4 used a wheelchair or walker for mobility. A review of an Incident and Accidents (I & A) Report with a date of 05/09/2025, revealed Resident #4 was involved in an “unusual occurrence” while on the facility van for a shopping outing with CNA #1 and the AD. A summary of the incident dated 05/09/2025 at approximately 12:15 PM, indicated the Assistant Director of Nursing (ADON) was notified by CNA #1 that on return travel to facility from an outing, Resident #4’s wheelchair tilted back, and the resident’s head hit the lift rack. CNA #1 pulled the facility van to the side of the street and stopped. CNA #1 and the AD assisted the resident back into an upright position. The Director of Nursing (DON) came to the scene of the incident and reported Resident #4 was in the van upon her arrival. Resident #4 was transported to the emergency room for evaluation. A review of a Progress Note dated 05/09/2025 at 9:30 PM revealed Resident #4 hit their head while in the facility van. The resident was sent to the area hospital for evaluation and returned to the facility at 9:30 PM. A body audit completed at the time of return revealed bruising with mild swelling to the left upper arm that was tender to touch, a knot on the back of the head, as well as redness and blanching to sacrum with complaint of mild pain from sitting for extended time at the hospital. Neuro checks were started at this time. A review of a Body Audit dated 05/09/2025, indicated at 9:30 PM Resident #4 had a knot and swelling to back of their head and bruising to left elbow, left upper arm, and left forearm. A review of an emergency room (ER) General Physician Note dated 05/09/2025, indicated Resident #4 stated they were on the facility transportation bus and their wheelchair tipped backwards. The note revealed an “Obvious bump on lower back part of skull, possible blood collection under the skin to left back bicep, and [Resident #4] reported a headache.” Computed Tomography performed on 05/09/2025 revealed mild back of the head swelling. The ER final diagnoses included head injury, closed, accidental fall, and back of the head swelling due to blood accumulation. Resident #4 was discharged back to facility 05/08/2025 at 5:28 PM. A review of an in-service training sign-in sheet dated 05/07/2025, indicated CNA #1 attended an in-service which covered “correct operation of the lift, correct procedure for loading and unloading a resident utilizing the van lift, correctly securing residents with proper tie down procedures, and manual operation of the lift. The course was named “Correct Lift Operation and Properly Securing Residents” and took place at the facility. A review of an inspection company invoice dated 05/15/2025 indicated the following: - Concern: safety inspection of lift, tiedown straps and belts due to an incident with a resident - Cause: At time of inspection the tiedowns were not in the proposition for transporting a wheelchair. No mechanical issues or damage was found with/on the tiedowns or the lap and shoulder belt assembly when vehicle was inspected. - Correction: Need an in-service training to show proper placement of retractors. Need to replace back tires and front windshield due to safety issues. Review of In-service Education Report titled “When Transporting an Elder Make Sure All the Following Are Observed” dated 05/09/2025 indicated “correct operation of the lift, correct procedure for loading/unloading elder on lift, correct securing of resident with the proper tie down procedures.” CNA #1 and the Maintenance Supervisor signed the in-service report. A review of an In-service Education Report titled “Transportation Van” dated 05/22/2025 indicated a new wheelchair with anti-tippers will be utilized on the van. Residents will not be transported in their personal wheelchair. During an interview on 08/05/2025 at 11:05 AM, Resident #4 indicated CNA #1 strapped the resident’s wheelchair in place and placed the seatbelt over the resident in the facility van before they left the facility. The resident indicated that CNA #1 and the AD were the two employees on the van. Resident #4 indicated on the way back to the facility, suddenly the resident’s head went back, and resident’s head was hit on the lift at the back of the facility van. The resident stated “The whole wheelchair and I went back. I was pinned with my chin to my chest.” The resident reported the employees stopped the van on the side of the road and helped them up. The resident referred to the incident as “a freak accident” and stated they had a “large goose egg big enough to see without feeling on the back of my head and my left shoulder and left arm had large bruising.” During an interview on 08/05/2025 at 12:12 PM, the AD indicated on 05/09/2025 Resident #4 went on a shopping outing in the facility van. She reported after shopping at a store, CNA #1 applied the straps onto Resident #4’s wheelchair, securing the resident for the travel back to the facility. She indicated they were about half-way back to the facility when the resident made a verbal sound that caught her attention. The AD reported she looked back, and the resident’s head was against the gate of the lift in the back of the van. The AD reported CNA #1 quickly pulled off the road and they assisted the resident up off the lift. She stated “I don’t even know how it happened. After the accident the wheelchair locks were locked, and all the straps were in place correctly. Shoulder strap and lap belt, each wheel (four) had its own strap and all were in place.” During a phone interview on 08/06/2025 at 11:27 AM, the van inspection company employee verified the repair order safety inspection for the facility van dated 05/15/2025. The van inspection company employee indicated on the invoice Cause: “at time of inspection the tie downs were not in the proposition for transporting a wheelchair” included a typo and the word “proposition” should have read “proper position.” The van inspection company employee indicated straps, or tie downs were also called retractors, and the retractors on the facility van were in the wrong spot, the wrong position. The employee stated “the ratchet straps were parallel to the ones behind it. The two ratchet straps in the back should be closer together so they hold the back of the chair.” The employee reported the way the retractors were positioned in the van could allow a resident to fall side to side or to tip backwards. During a phone interview on 08/07/2025 at 8:16 AM, the van inspection company manager verified the repair order safety inspection for the facility van dated 05/15/2025. The manager indicated on the invoice the Cause: “at time of inspection the tiedowns were not in the proposition for transporting a wheelchair” the word proposition was misspelled and should be proper position and not “proposition”. The manager indicated the tie downs or retractors were not placed in the proper area. The manager reported that when the facility requested the safety inspection following an incident, the facility was instructed to not move anything in the van before the inspection was completed. The manager also reported the facility maintenance man brought the van in and took part in some education on the proper placement of the tie downs. The van inspection company manager stated, “The maintenance man said to me I don’t think we have ever been shown this way”. The manager reported the tiedowns could not have been tight on the wheelchair the way they were positioned. During an interview on 08/07/2025 at 11:21 AM, the Maintenance Director (MD) reported he drove the van back to the facility without passengers after the incident. He reported he took the facility van to be inspected on 05/15/2025. He reported the inspection made recommendations for new tires and a new windshield and the facility did get new tires and a new windshield. The MD stated “The guy checked the straps and said that it was good, he wanted to make sure the tie downs were correctly placed. There were no issues with how they were placed.” The MD verbalized he did not read the printed safety inspection report. He reported the inspector in-serviced him on how to spread out the straps to keep the wheelchair from “wobbling”. He indicated he relayed the in-service to the admin. During an interview on 08/07/2025 at 11:45 AM, the Administrator reported she received a call from the ADON reporting Resident #4 hit their head on the lift of the facility van on the way back from a shopping outing and the van was pulled over on the side of the road. The Administrator indicated she went to the scene and called the ambulance and local sheriff’s office on the way there. The Administrator reported when she got to the van she checked on the resident first. The Administrator indicated Resident #4 was still in the wheelchair and the restraints were in place. The Administrator reported that the resident stated they “adjusted” themselves in the chair. The Administrator reported Resident #4 was transported to the emergency room via ambulance. She reported that the Maintenance Director was called to come pick up the van. The Administrator reported an appointment was made to have the van inspected and the staff were instructed to leave everything as it was and avoid moving anything. The Administrator reported neither she nor any other staff moved anything in the van. She stated the safety inspection indicated “there was no problem with the tract system, there was nothing wrong.” The Administrator stated “I called to get an update from them (inspectors of the van). They said nothing was wrong.” She reported the inspector did say the van needed new tires and a new windshield. The Administrator stated, “it was a ‘freak accident’” and Resident #4 only had a very small knot on the back of [the resident’s] head that was gone the next day. “I really think [Resident #4] leaned back repositioning self and hit head.” During an interview on 08/07/2025 at 4:15 PM the Administrator reported there was not a facility policy for accidents.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #82) of 1 sampled resident reviewed for elopement. The lack of an effective monitoring plan resulted in Resident #82 eloping from the facility and being found walking in the grass on the side of a public highway, approximately 100 yards from the resident's residence. 1. Resident #82 followed two other residents out to the back patio for their smoke break and staff only checked on residents every 5 to 10 minutes when they were outside the residence. Resident #82 was admitted on [DATE] with a diagnosis of Alzheimer's disease and had an Admission Assessment which indicated the resident was at risk of wandering. On 04/23/2024, Resident #82 verbalized to staff that she lived close by and wanted to walk home. Staff were instructed to closely monitor the resident due to making that statement. At the time of the survey, there were 35 residents residing in the cottages who were identified as at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J; 2. Based on observation, interview and record review, the facility failed to ensure aerosol cans were removed from a resident's room to decrease the potential for harm; 3. failed to ensure hazardous chemicals and equipment were secured in a closed, locked room, from wandering residents. This failed practice had the potential to affect 1 (Resident #29) of 8 residents in Cottage 4 that ambulated or self-propelled; 4. failed to ensure adequate supervision was provided, assistive devices were in place, and interventions were implemented to decrease the potential for accidents for 1 (Resident #20) of 1 resident who was at risk for falls; 1.) Resident #82 was admitted on [DATE] and had an Admission Assessment which indicated the resident was at risk of wandering. On 04/23/2024, Resident #82 verbalized to staff that [Resident #82] lived close by and wanted to walk home. A staff member was instructed to closely monitor Resident #82 due to making that statement. At the time of the survey, there were 35 residents residing in the cottages who were identified as at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/23/2024 around 6:00 PM when Resident #82 was seen walking in the grass on the side of a public highway approximately 100 yards from the resident's residence by a facility staff member who was walking to her vehicle after work. The resident was seen exiting the building with two other residents by a staff member. However, the resident left the area without staff knowledge. The Administrator, Administrator Assistant, Assistant Director of Nursing (ADON) and Nurse Consultants were notified of the IJ on 04/25/2024 at 12:39 PM. A Plan of Removal was requested. The Removal Plan was accepted by the State Survey Agency on 04/26/2024 at 3:29 PM. The IJ was removed on 04/30/2024 at 3:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. The findings are: Resident #82 was admitted on [DATE] with a diagnosis of Alzheimer's disease as documented on the Order Summary. A Care Plan initiated 04/24/2024 documented Resident #82 was an elopement risk/wanderer and was transitioned to the Secure Cottage and was to be observed for any changes in wandering or exit seeking behaviors. On 04/23/2024 at 8:04 PM, the facility submitted an Incident and Accident report to the Office of Long-Term Care that documented Resident #82 had walked away from the campus and was found by the Admission and Marketing Director and brought back to the campus. A Wandering Risk Scale dated 04/23/2024 documented Resident #82 had a score of 9 (9-10 indicates at risk for wandering/elopement). On 04/24/2024 at 12:43 PM, Resident #82 was sitting in a chair in the room looking at a book. Resident #82 was asked if Resident #82 knew why resident was moved to a new room and resident replied, I may have wandered off. Resident #82 had no memory of the incident on 04/23/2024. On 04/24/2024 at 1:04 PM, the Admissions and Marketing Director was interviewed, and she was asked to describe the incident regarding Resident #82, and she stated, I was getting ready to leave around six o'clock. I was going to my car to leave and looked up and I saw [Resident #82]. I didn't know who it was at first. I took off running when I saw [Resident #82] to stop [Resident #82] and redirect [Resident #82] back to the facility. She admitted the resident was on the road going to [Resident #82]'s right. She added Resident #82 was still on the left side of the street and was about 30-40 yards from the stop sign. She stated [Resident #82] stated [Resident #82] was fine and that [Resident #82] stated [Resident #82] was trying to get to a cousin's house because the resident's spouse was supposed to be there to pick up [Resident #82]. The Admission and Marketing Director stated when Resident #82 was told they needed to go back to the facility, Resident #82 immediately came with her. She added that the Minimum Data Set (MDS) Coordinator and Administrator saw her running, knew something was wrong and came to her and [Resident #82] after they were back on facility grounds, and they (Administrator and MDS Coordinator) walked the resident the rest of the way and she left. On 04/24/2024 at 2:50 PM, Certified Nursing Assistant (CNA) #11, was asked when she saw Resident #82 last and she stated it was after 5:30 PM and going on 6:00 PM after supper. She stated Resident #82 had got up from the table and followed two residents to the back patio to smoke. She added Resident #82 did not smoke when asked and that she thought the resident liked the company but usually came back it. She confirmed that no staff member went outside with the residents and that she was not aware that the nurse had told a co-worker to keep an eye on Resident #82. CNA #11 was asked how she knew which residents needed supervision and she stated she had not been told about anyone who needed supervision. On 04/24/2024 at 3:17 PM, CNA #12 was asked if residents were allowed to be on the porch alone and he stated, Yes, if they are not visually disoriented, but we have to keep an eye on them, depending on who they are. If it's someone new, we try to check on them every 5 to 10 minutes. He confirmed that CNAs were responsible for watching the residents when they were on the porch. He was asked if he was familiar with [Resident #82] and he stated it was his second day with the resident since the resident's admission. CNA #12 denied knowing if the resident had any exit seeking behavior. He admitted the last time he saw Resident #82 was about 5:30 PM to 5:45 PM when Resident #82 was sitting at the dinner table eating. He confirmed that he was told by the nurse to keep an eye on Resident #82 because the resident could possibly wander off. On 04/24/2024 at 4:39 PM, Registered Nurse (RN) #1 was asked to describe the incident regarding Resident #82 and she stated, About 4:50 [pm] I was packing up my things and an aide brought [Resident #82] in from the back porch to the library and the aide stated she didn't want [Resident #82] to get hurt because they were mowing and then [Resident #82] stated [Resident #82] thought [Resident #82] lived pretty close down the street and [Resident #82] thought [Resident #82] could walk there. So, we re-orientated [Resident #82] and took [Resident #82] back to [Resident #82]'s room. Then I was about to go across the street and the aide, at the CNA [documentation area], I told to keep an eye on the elder because [Resident #82] made a comment that [Resident #82] lived down the street and thought [Resident #82] could walk there and I didn't want [Resident #82] to try to leave, thinking that [Resident #82] lived there from the Alzheimer's. At that point the resident was in [Resident #82]'s room and [Resident #82]'s door was visible from the [documentation area]. After that, I went to [NAME] Cottage for my 5 o'clock med [medication] pass. She confirmed Resident #82 did not show any exit seeking behaviors on her shift, but the night nurse stated Resident #82 commented about wanting to go home. On 04/24/2024 at 05:34 PM, the Administrator was interviewed and stated that she and the MDS Coordinator were walking to their vehicles around 5:50 PM and observed the Admissions and Marketing Director talking to Resident #82. She stated they met Resident #82 and the Admissions and Marketing Director and walked Resident #82 back and Resident #82 was taken to the Secure Cottage and [Resident #82]'s belongings moved. The Administrator stated she met with the staff and had the MDS Coordinator start running risks assessments. The Administrator added, I sent nursing, ADON, to do a body audit immediately and the Nurse Practitioner was on the phone with the ADON, and the 15 minutes checks were started, and all notifications were being done and family was notified. She stated she sent the Dietary Assistant/CNA to the cottages with the in-services to make sure they understood and to let them know that she would follow before she left but she needed them [in-services] to go out immediately. She had another staff nurse to get witness statements. She stated, After I left 3 [Cottage #3], I did go find the nurse and I told her to do an I&A [incident and accident] and that I needed her to make sure [Resident #82] meds and belongings got transferred to Cottage 1. The Immediate Jeopardy was removed on 04/26/2024 at 03:00 PM when the following Plan of Removal was implemented by the facility: Upon notification to Administrator that Resident #82 was observed off campus, the Resident was returned to the campus by the Admission Coordinator, a body audit was conducted by a Licensed Practical Nurse with no negative findings and Resident #82 was placed in the secure cottage on 04/23/2024 at 06:15 PM. Resident #82's wandering risk assessment was reassessed by the Minimum Data Set Coordinator and the plan of care was updated to include risk of wandering on 04/23/2024. CNA in Secure Cottage Began 15 minute checks on Resident #82 on 04/23/2024. These 15-minute checks will continue until Resident #82 no longer exhibits exit seeking behavior. The Administrator and Assistant Administrator began in-service training for all staff on duty on 04/23/2024 related to abuse, neglect, and elopement. All other staff will be trained before coming on duty on abuse and neglect and elopement. The training included if an elder seems more confused, is exit seeking, found to have an increase in wandering or any change of condition, staff are to notify a supervisor/nurse immediately and staff to perform more frequent checks on them. This has a completion date of 04/26/2024. Facility Registered Nurse and Licensed Practical Nurse reassessed all other elders on current census for their wandering risk assessment on 04/23/2024. Resident's care plans and wandering assessments will indicate if a resident is at risk for wandering. All corrections were completed on 04/26/2024. The Administrator provided a Missing Resident/Elopement Protocols policy on 04/24/2024 that documented, .It is the policy of the Green House Cottages of Southern Hills to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy of the Green House Cottages of Southern Hills to implement its elopement protocols immediately to locate the resident in a timely manner . On 04/26/2024 at 12:30 PM, the Administrative Assistant provided an Inservice Education Report on Elopement, a second one on Abuse and Neglect Investigation and Reporting and a third one that documented, All elders are to be monitored every 15 minutes . with different signatures and titles on each in-service. Onsite Verification: The IJ was removed on 04/26/2024 at 03:00 PM after the survey team performed an onsite verification that the Removal Plan had been implemented. On 04/30/2024 at 10:45 AM, the Surveyor entered the facility to verify removal of the immediate jeopardy. Reviewed Resident #82's placement, verified resident census for the secure cottage. Resident #82's wandering risk assessment was reassessed by the Minimum Data Set Coordinator and the plan of care was updated to include risk of wandering on 04/23/2024. Reviewed Certified Nursing Assistant (CNA) in Secure Cottage l5 minute checks on Resident #82 on 04/23/2024. The checks began on 04/23/2024 at 7:00 PM, and ended on 04/24/2024 at 7:00 PM, with no notation of exit seeking behavior since 04/24/2024 at 10:30 AM, noted Resident 'beating on door.' On 04/30/2024 at 2:10 PM, Resident #82 observed sitting in the resident's room of the secure cottage pleasantly visiting with a peer. No exit seeking or wandering behaviors observed. Reviewed staff in-service related to abuse, neglect, and elopement that began on 04/23/2024. The Assistant Administrator provided an audit list of employees for the facility to verify all staff were in-serviced by 04/26/2024. The Assistant Administrator reported the audit list was compared to staff signatures and phone calls to staff so they could verify every staff member had been in-serviced. On 04/30/2024 between 12:00 PM and 2:40 PM, 20 Certified Nursing Assistants, 3 Licensed Practical Nurses and 1 Registered Nurse that work various shifts, were interviewed to verify they received and understood the in-service. They were able to verbalize the training included that if a resident seemed more confused, is exit seeking, found to have an increase in wandering or any change of condition, staff are to notify a supervisor/nurse immediately and staff to perform more frequent checks on them. This had a completion date of 04/26/2024. Reviewed resident audit list for wandering risk assessment on 04/23/2024. Two residents were identified with a change in risk, verified both resident's care plans were updated to indicate resident is at risk for wandering. The Administrator and the Regional Consultant were informed of the Immediate Jeopardy Plan of Removal with a Completion Date of 04/26/2024 verified removal on 04/30/2024 at 03:00 PM. 48390 2). A facility policy titled, Accident Hazards Prevention, dated 04/24/2024, indicated, The environment will be free from accident hazards as is possible. On 04/22/2024 at 11:24 AM, the Surveyor observed in room [ROOM NUMBER] an aerosol can of air freshener on the open shelf in the room next to the door. Also observed on the shelf in the bathroom was an aerosol can of [named] air freshener in the open cabinet. On 04/22/2024 at 01:20 PM, the Surveyor went into room [ROOM NUMBER] and observed a resident lying in a bed. A can of [named] aerosol air freshener, 8.3 ounce size, was out on the shelf in the resident's room. In the bathroom the cabinet was open and a can of aerosol air freshener, 8.8 ounce size, was observed on the shelf. During an interview on 04/25/2024 at 04:13 PM, Licensed Practical Nurse (LPN) #3 was asked if a resident could have an aerosol can in their room. LPN #3 indicated that they could not have anything like that at all. During an interview on 04/25/2024 at 04:17 PM, Certified Nursing Assistant (CNA) #9 was asked if a resident could have an aerosol can in their room. CNA #9 stated No. CNA #9 was asked if any resident in Cottage 3 had an aerosol can in their room. CNA #9 indicated not to my knowledge. 48977 3). On 04/22/2024 at 10:50 AM, the Surveyor observed keys in the doorknob of a closet. The Surveyor opened the door and noted full and empty portable oxygen tanks sitting on the floor behind boxes of items to provide care (razors, saving cream, gloves, oral swabs, incontinence briefs, toilets paper). On 04/22/2024 at 10:53 AM, the Surveyor asked Registered Nurse (RN) #1 if the door should be unlocked? RN #1 stated, No. The Surveyor asked why is it important that the door remains locked? RN #1 stated, There is stuff in there like mouth wash, razors, and oxygen that the elders could get into and it could be harmful to them. The Surveyor asked whose keys were in the door. Certified Nursing Assistant (CNA) #1 walked up and stated, mine and removed the keys from the doorknob. On 04/25/2024 at 10:37 AM, the Surveyor asked the Assistant Director of Nursing (ADON), if the door to the closet used to store items to provide care, clean linens, and portable oxygen tanks should be locked? The ADON stated, Yes. The Surveyor asked with the closet containing portable oxygen tanks, could it be a danger to the residents? The ADON stated, Yes. On 04/25/2024 at 11:39 AM, the Surveyor was provided a policy titled, Accident Hazards Prevention that documented Resident Environment. The Environment will be free from accident hazards as is possible. A Life Safety manual will be maintained. 49596 4). Resident #20 had diagnoses of dementia, psychotic disturbance, anxiety, and delirium. Fall Assessments dated 03/29/2024, 3/11/2024, 3/1/2024, 12/28/2023, 10/10/2023, 10/7/2023, and 10/1/2023 all identified Resident #20 to be a High Fall Risk. Resident #20 had a BIMS of 7, as identified on a MDS dated [DATE], which indicated Resident #20 had severe cognitive impairment. Resident #20 ' s Care Plan dated 04/03/2024 identified Resident #20 to be at risk for falls and dates for falls of 10/01/2023; 10/07/2023; 10/20/2023; 01/03/2024; 02/01/2024; 03/11/2024. The Care Plan initiated 09/20/2023 with revision of 04/08/2024 documented: Resident #20 will be free of falls through the review date. Date Initiated: 04/03/2024. 10/01/2023 encouraged to use the call light for assistance; 10/20/2023 blanket was removed from w/c [wheelchair], encouraged to lock brakes on w/c; 10/07/2023 fall mat to floor right side of bed; 02/01/2024 maintenance inspected threshold to door. And 03/11/2024 fall mat to floor, new low bed ordered by hospice. A Nursing Progress Note dated 03/11/2024 at 19:43 (7:43) PM documented, The elder was reaching for a drink off the nightstand, and she slid out of the bed hitting her head on the bedside table. She has a small laceration to the top of the scalp on the left side. The area was cleaned, and the bleeding stopped. She was assessed and assisted to a wheelchair. Neuros [neurological checks] started at this time. The hospice nurse was notified and came to see the elder also. MD [Medical Doctor] was notified of the fall along with family member . A Nursing Progress Note dated 03/13/2024 at 11:23 PM documented, .Continues on observation for fall. No c/o [complaints of] px [pain] or discomfort voiced at this time. Currently resting in bed with bed in lowest position. No acute distress noted. Will continue with current plan of care. C/L [call light] in reach. A MDS Progress Note dated 04/03/2024 at 03:07 PM documented, Quarterly MDS Assessment Completed. Elder requires staff assistance with some functional abilities . Fall X2 noted during the look back period. No skill therapy services, referrals or plan of discharge. Elder continues with [named provider] hospice services. On 04/22/2024 at 10:25 AM, Resident #20 was observed lying in bed, the bed was not in the lowest position, the bed was at normal height. On 04/22/2024 at 11:50 AM, Resident #20 was observed lying in bed, the bed was not in the lowest position. On 04/22/2024 at 02:05 PM, Resident #20 was observed lying in bed, the bed was not in the lowest position. On 04/23/2024 at 10:15 AM, Resident #20 was observed in bed, the bed was not in the lowest position. The bed height was that of a normal hospital bed. On 04/23/2024 at 2:20 PM, Resident #20 was observed in bed. The bed was at normal height, and not in low position. The bed height was that of a normal hospital bed. On 04/23/2024 at 03:15 PM, Resident #20's bed height was that of a normal hospital bed. During continued rounds in the cottage, the resident was observed attempting to get out of bed. On 04/23/2024 at 03:18 PM, CNA #4 stated that staff keep Resident #20 ' s bed in its lowest position when Resident #20 is not eating or drinking. On 04/23/2024 at 03:20 PM, LPN #1 stated the bed was to be kept in the lowest position when the resident was in it, this was an intervention after a fall. It is supposed to be kept down, at all times, except when they are changing the resident. On 04/25/2024 at 08:59 AM, Resident #20's bed was observed not to be in the lowest position. CNA #4 measured the bed to be at 69 inches, the height was verified by CNA #11. On 04/25/2024 at 02:45 PM, the ADON stated they do not have a policy on bed height. The Surveyor asked the ADON, How do you expect the staff to use the Hi-Low bed for Resident #20? The ADON stated, They are to leave it in the lowest possible position. They are not to leave her in a high position. The Surveyor asked, If the resident requested to remain in the high position, how would you instruct the staff? The ADON stated, We can't leave her up because if she fell at that height, it could cause a serious injury. It is for her safety.

Based on observation, record review and interview, the facility failed to ensure (1) food preparation equipment was free of peeling and chipped paint to prevent potential food borne illness for resident who received meals from the kitchen in Cottage #6, (2) expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 7 of 7 kitchens, (3) foods stored in the freezer, refrigerator and dry storage area were covered, sealed, dated and were stored in accordance with the manufacturer's instructions for residents who received meals from the kitchen in Cottage #7, (4) that 1 of 7 ice scoop holder was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from the kitchen in Cottage #7, and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for residents who received meals from the kitchen in Cottage #2. The failed practices had the potential to affect 12 residents who receive meals from the kitchen in Cottage #1; 12 residents who receive meals from kitchen on Cottage #2; 12 residents who received meal trays from the kitchen in Cottage #3; 12 residents who received meal trays from the kitchen in Cottage #4; 11 residents who received meal trays from the kitchen in Cottage #5; 12 residents who received meal trays from the kitchen in Cottage #6; and 12 residents who received meal trays from the kitchen in Cottage #7. The findings are: 1. On [DATE] at 09:44 AM, the following observation was made in the refrigerator located in the kitchen in Cottage #7. a. An opened gallon of milk was on a shelf with no open date on it. b. An open bottle of prune juice was on a shelf, with no open date on the bottle. c. A packet of sliced oven roasted turkey was on a shelf and had sell by date of [DATE]. d. An opened bottle of lemon juice with no open date on the bottle. e. A bottle of caramel sauce. There was no date on the bottle to indicate when it was opened. f. A bottle of cocktail sauce. There was no open date on the bottle. g. Two bottles of Worcestershire sauce. No date on the bottle to indicate when it was opened. h. A bottle of chocolate syrup with no open date on it. i. Three opened bottles of tomato ketchup. j. A container of parmesan cheese with no open date on it. k. A bottle of Italian dressing with open date on it. l. A bottle of traditional tomato sauce with no open date on the bottle. m. An opened bottle of tartar sauce. No date on the bottle to indicate when it was opened. n. An opened bottle of real mayonnaise with no open date on it. o. A bottle of apple cider vinegar on shelf that had an expiration date of [DATE]. p. A box of nectar sweetened tea with lemon flavor. There was no received or opened date on the box. q. A gallon of medium picante sauce with no open date on the gallon. 2. On [DATE] at 10:01 AM, the following observations were made in the kitchen cabinet in Cottage #7: a. An opened bottle of lemon juice. Some of the juice has been used from it. The manufacture specification on the bottle documented, Refrigerate after opening. The surveyor asked Certified Nursing Assistant (CNA) #2 what they use lemon juice for? She stated, We use it when we make lemon pie. b. An opened bottle of Italian dressing and an opened bottle of thousand land. The manufacturer specifications on the bottles documented, Refrigerate after opening. The surveyor asked CNA #7 if Italian dressing and an opened bottle of thousand island be refrigerated after opening. She stated, Yes. Someone must have put them there. c. A box of raisins and a box of baking soda with no received or opened dates on them. d. A container of ground cumin. e. A box of iodized salt. f. Ground cinnamon. g. A container of lemon pepper seasoning salt. h. A container of rubbed sage. 3. On [DATE] at 10:13 AM, the following food items stored on a shelf in the freezer were not covered, sealed and or dated when opened or received: a. An opened bag of cheese omelets. b. Two bags of chicken tenders. c. An opened bag of hash brown. d. An opened bags of chicken tenders. e. An opened bag of bread sticks. f. An opened bag of sausage. g. An opened box of biscuits. h. A box of chicken pot pie had no received date on it. i. A box of beef pot pie and a box of turkey pot pies have no received date on them. 4. On [DATE] at 10:16 AM, the following observations were made in the refrigerator and on the rack in the storage room: a. A container of sour cream on a shelf in the refrigerator had an expiration date of [DATE]. b. A container of cottage cheese on a shelf in the refrigerator had an expiration date of [DATE]. c. An opened container of chopped garlic was on a shelf, there was no open date on the container. d. An opened bag of potato chips was on the rack in the storage room. The bag was not sealed and did not have a date when it was opened. e. An opened bag of tornillos chips was on the rack in the storage room. The bag was not sealed. There was no date to indicate when it was opened. f. A 8 count bag of hamburger buns was on the rack with an expiration date of [DATE]. g. Two of 2 bags of bread on the rack had an expiration date of [DATE]. h. An opened box of fish fry crumbs was on the rack. The box was not covered or sealed. The lead CNA stated, We normally check the dates on the bread and if they have expired, we pull them out and throw them away. We have done it this morning. 5. On [DATE] at 10:23 AM, the ice scoop holder on the wall by the ice machine in the storage room had water standing with brownish residue floating on it. The ice scoop was directly resting on the residue. The Surveyor asked the lead CNA how much was in the ice scoop holder, to describe what was observed in the water, who uses the ice from the machine and how often it was cleaned. She stated, About a cup of water and had brownish substances floating on it. We clean it once a week. We use it to fill beverages served to the residents at mealtimes and also use it to fill the water cups in the residents' rooms. 6. On [DATE] at 10:00 AM, initial rounds in kitchen in Cottage #6 were conducted with the CNA #4. The microwave located on the food preparation counter had a gray finish peeling off the inside top. Certified Nursing Assistant #4 took a wet white towel and whipped it across the surface and dark particles came off onto the towel. 7. On [DATE] at 10:10 AM, Maintenance #1 came in Cottage #6 and looked at the surface, he peeled some of the surface off and said the unit needed to get a new one due to the paint peeling off. The Surveyor asked Maintenance #1 if he had received a work order on this microwave. Maintenance #1 stated, No. 8. On [DATE] at 10:07 AM, the following observations were made on a shelf in the refrigerator in the kitchen area in Cottage #6: a. A partial jug of milk that had expired [DATE]. b. A gallon jug with red liquid in it had not been dated. c. A quart of half and half had expired on [DATE]. d. A carton of (fortified nutritional shake oral supplement) expired on [DATE]. e. A box of orange juice expired on [DATE]. 3. On [DATE] at 10:20 AM, the freezer in the storage room contained 2 (Fast Food Business) cups of ice. CNA#4 stated it belonged to a staff member. When asked where the staff was to store their food items, CNA #4 stated, We store it in the refrigerators, indicating the same one with the resident food. 4. On [DATE] at 10:25 AM, a dented can of tomato soup was on the shelves where food intended to be used was stored. 5. On [DATE] at 10:44 AM, the utensil drawer had a spatula with several areas chipped off. The Surveyor asked CNA #4 what the spatula was used for. CNA #4 stated it was used for icing cakes. The Surveyor asked what problem she saw with the spatula. CNA #4 stated pieces could chip off in the icing. 6. On [DATE] at 04:15 PM, two cartons of nectar sweetened lemon flavor tea were on a rack in the storage room with an expiration date of [DATE]. CNA #2 stated, We threw all nectar thickened liquid away. We missed those 2 cartons. We don't even have anyone on nectar thickened liquid anymore. 7. On [DATE] at 04:18 PM, the following spices were stored in the cabinet above the food preparation counter with no open date on them: a. A container of chili powder. b. A container of lemon pepper seasoning. c. A container of ground cayenne pepper. d. A container of mediterranean style ground oregano. e. A container of ground cumin. 8. On [DATE] at 10:48 AM, the following observations were made in the refrigerator in Cottage #5. a. A small individual tub of tuna salad did not have a receive date on it. b. A quart of buttermilk that expired [DATE]. 9. On [DATE] at 10:55 AM, the following observations were made in the freezer in Cottage #5: a. A ham in the freezer in a large plastic bag on a shelf was freezer burned and contained white ice particles. b. Three bags of california blend vegetables did not have dates and were freezer burned with white ice particles on the vegetables inside the bag. c. Two packages of green beans are not dated. d. Two packages of zucchini had freezer burned containing white ice particles on the vegetables. The Surveyor asked CNA #6 how these foods appeared. CNA #6 stated they appear freezer burned. The Surveyor asked CNA #6 if these foods were usable. CNA #6 stated she did not know if she could use them. 10. On [DATE] at 11:05 AM, a #10 can of cherry pie filling was dented and stored on the shelves for food to be used. 11. On [DATE] at 11:15 AM, the following observations were made in the refrigerator in Cottage #5. a. A jar of relish on a shelf was not dated. b. A zip lock bag containing a head of cabbage not sealed. 12. On [DATE] at 11:17 AM, there was an open bag of tortilla chips on the rack in the storage room. The bag was not sealed. 13. On [DATE] at 10:34 AM, in Cottage #4 the following spices were stored in the cabinet above the food preparation counter with no open dates on them: a. An open box of iodized salt was not covered. b. A container of ground cumin. c. A container of ground pepper. d. A container of garlic powder. e. A container of ground mustard. f. A container of lemon pepper. g. A container of cinnamon. h. A container of ground oregano. i. A container spanish paprika. j. A container of light chili powder. k. Two containers of breadcrumbs. l. A container of rubbed sage. m. A container of traditional seasoned salt. n. A bottle of vanilla extract. o. An opened box of baking soda. The box was not covered. p. A bottle of worcestershire sauce. q. A container of cornstarch. r. A container of peanut butter. 14. On [DATE] at 10:37 AM, the following observations were made on a shelf in the refrigerator and on the rack in the storeroom with no open date on them: a. An opened container of chopped garlic in water. b. A gallon of enchilada sauce. c. A bottle of italian dressing. d. A container of kosher dill spears pickles. e. A container of sour cream on a shelf in the refrigerator had an expiration date of [DATE]. f. A bag of bread on the rack had an expiration date of [DATE]. g. Two of 2 bags with 8 counts of hot dog buns each had an expiration date of [DATE]. h. A box of nectar thickened flavor water on the rack in the storage room had an expiration date of [DATE]. i. A bottle of prune juice on the rack with an expiration date of [DATE] j. An opened box of fish fryer crumbs was on a shelf in the storage room. The box was not covered or sealed. 15. On [DATE] at 10:39 AM, the following observations were made in the freezer in the storage room: a. Two bags of opened pie shells were on a shelf in the freezer. The bags were not sealed. b. An opened bag of biscuits was in the freezer compartment. The bag was not sealed. 16. On [DATE] at 11:30 AM, the following spices were stored in the cabinet above the food preparation counter in Cottage #3 with no open dates on them. a. A container of ground lemon pepper. b. A container of mustard. c. A container of garlic powder. d. A container of ground mustard. e. A container of cinnamon. f. A container of creole seasoning. g. A container of celery seasoning. h. A container of light chili powder. i. A container of rubbed sage. 17. On [DATE] at 11:33 AM, the following observations were made on a shelf in the refrigerator with no open date. a. A bottle of worcestershire sauce. b. A bottle of cocktail sauce. c. A bottle of ranch dressing. d. A container of parmesan cheese. e. A gallon of enchilada sauce. f. A plastic bag of shredded cheese was not sealed. g. A container of cottage cheese had an expiration date of [DATE]. h. A bottle of prune juice had expiration date of [DATE]. 18. On [DATE] at 02:32 PM, a container of cottage cheese was on a shelf in the refrigerator in the storage room with an expiration date of [DATE]. 19. On [DATE] at 02:33 PM, three bags of hamburger buns with 8 counts in each bag were on the rack in the storage room with an expiration date of [DATE]. 20. On [DATE] at 02:27 PM, the following observations were made in the refrigerator of Cottage #1: a. An opened resealable bag of mozzarella cheese was on a shelf. The bag was not sealed. There was no date to indicate when the bag was opened. b. A container of cottage cheese had an expiration date of [DATE]. 21. On [DATE] at 02:29 PM, the following spices were stored in the cabinet above the food preparation counter with no open date on them: a. A container of garlic powder. b. A container of ground black pepper. c. A container of onion powder. d. A container of celery salt. e. A container of cinnamon. f. A container of ground cumin. g. A container of ground mustard. 22. Two bags with 8 hamburger buns in each bag were on the rack in the storage room with an expiration date of [DATE]. 23. On [DATE] at 01:43 PM, the following spices were stored in the cabinet above the food preparation counter in Cottage #2 with no open date on them. a. A container of parmesan grated cheese. b. A container of garlic powder. c. a container of celery seed. d. A container of ground mustard. e. A container of mediterranean style ground oregano. f. A container of ground cayenne pepper. g. A container of rubbed sage. 24. On [DATE] at 01:51 PM, the following observations were made in the refrigerator compartment: a. An opened package of oven roasted turkey was in the compartment with no open date on it. b. An opened package of smoked ham was in the compartment with no open date indicated on the package. c. An opened bottle of strawberry jelly was on a shelf in the refrigerator and there was no open date on it. d. An opened bottle of grape jelly was on a shelf and there was no open date on it. 25. On [DATE] at 02:01 PM, the following observations were made in the freezer compartment: a. An opened bag of sausage. The bag was not sealed. b. An opened bag of biscuits. The bag was not sealed. 26. On [DATE] at 02:03 PM, the following food items stored on a shelf in the freezer in the storage room did not have a received date on them: a. A bag of battered sweet corn nuggets. b. Carrots. c. Breaded okra. 27. On [DATE] at 02:07 PM, a container of cottage cheese on a shelf in the refrigerator had an expiration date of [DATE]. 28. On [DATE] at 02:09 PM, the following observations were made on the rack in the storage room: a. An opened bag of corn chips was on the rack. There was no open date on the bag. b. A bag of bread was on the rack with expiration date of [DATE]. 29. On [DATE] at 03:46 PM, CNA #8 turned on the sink faucet and obtained water in a pot. After obtaining the water, she turned the water faucet off with her gloved hands, contaminating them. She then placed the pot of water on the stove. She opened a bag of tator tots that was on the counter. Without changing gloves and washing her hands, she removed tator tots from the bag and placed them inside the deep fryer basket to be fried and served to the residents for the supper meal. The Surveyor asked CNA #8 Should you have used the same glove that you wore when you turned and on and turned off the faucet to remove tator tots? She stated, I should have removed the gloves and washed my hands. 30. On [DATE] at 07:59 AM, CNA # 9 picked up glasses by their rims and placed them on the counter to be used serving beverages to the residents for breakfast. The Surveyor asked CNA #9 what should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 31. A facility policy titled Handwashing: Follow these five steps every time documented, Wet your hands with clean, running water (warm or cold), and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 1 resident who received pureed diets in Cottage #4, 1 resident who received pureed diets in Cottage #6, and 3 residents who received pureed diets in Cottage #7. The findings are: 1. On 04/22/2024 at 12:28 PM, the lead Certified Nursing Assistant (CNA) in Cottage #7 used a 4-ounce spoon to place 4 servings of cut green beans into a blender and pureed. She poured it into a divided plate on the counter. The consistency of the pureed green beans was runny and was not formed. Water was separated from the beans. 2. On 04/22/2024 at 12:30 PM, the lead CNA placed 4 servings of bread sticks into a blender, added whole milk and pureed. She poured the pureed bread into a divided plate. The consistency of the pureed bread was lumpy, and not smooth. The consistency of the pureed chicken alfredo on the plate to be served to the residents on pureed diets was lumpy and not smooth. 3. On 04/22/2024 at 12:03 PM, CNA # 2 in Cottage #6 used a 4 ounce spoon to place 2 servings of chicken alfredo into a blender, added milk and pureed. She poured the pureed chicken alfredo on a divided plate. The consistency of the chicken alfredo was gritty and not smooth. There were pieces of noodles and chicken. 4. 3. On 04/22/2024 at 12:33 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed chicken alfredo was a little gritty. Pureed cut green beans was loose and pureed bread was a little gritty. 5. On 04/23/2024 at 08:46 AM, the residents who received pureed diets from the kitchen in Cottage #7 were served pureed sausage and pureed French toast sticks for breakfast. The consistency of the pureed sausage was lumpy, runny and was not smooth. There were pieces of meat visible in the mixture. The consistency of the pureed French toast sticks was thick. At 08:50 AM, the Surveyor asked Medication Assistant-Certified #1 to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed sausage was mushy, running and had pieces of sausage in it. Pureed French toast was thick.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for 2 (Residents #7 and #29) sampled residents. The findings are: 1. Resident #7 had diagnoses of dementia and pelvic/perineal pain. a. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/2024 documented Resident #7 scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. b. Resident #7 had a Physician's Order for Diclofenac Sodium External Gel 1 % to be applied as needed for localized pain. c. Resident #7's Care Plan documented that the resident has pelvic and perineal pain and included intervention as follows: administer pain medications as ordered/needed, notify MD/Practitioner if not effective, administer PRN (as needed) pain medications as ordered to alleviate pain or for breakthrough pain. d. On 04/22/2024 at 10:10 AM, the Surveyor observed a container of Diclofenac Sodium 1% in the Resident's bathroom on a shelf. e. On 04/22/2024 at 12:13 PM, the Surveyor observed a container of Diclofenac Sodium 1% in the Resident's bathroom on a shelf. f. On 04/23/2024 at 08:45 AM, the Surveyor observed a container of Diclofenac Sodium 1% in the Resident's bathroom on the shelf. g. On 04/23/2024 at 09:10 AM, the Surveyor observed a container of Diclofenac Sodium 1% in the Resident's bathroom on the shelf. h. On 04/23/2024 at 09:10 AM, the Surveyor asked Medication Administration Certified aide (MA-C), while in the Resident's bathroom, Can you tell me what you see that should not be unlocked in a Resident's room? MA-C identified zinc cream, arthritis cream (Diclofenac), and aerosol air freshener. 2. Resident #29 had diagnoses of Down syndrome, adjustment disorder, and other specified mental disorders due to know physiological condition. a. A Quarterly MDS with an ARD of 04/20/2024 documented Resident #29 had short term and long-term memory problems. According to care plan Resident 29 was dependent on staff, mother, family for meeting emotional, intellectual, physical and social needs related to Cognitive deficits mental disability. b. A review of Resident #29's physician's orders revealed there was no order in place for triple antibiotic ointment. c. On 04/22/2024 at 10:25 AM, the Surveyor observed 3 sample size packs triple antibiotic ointment on a shelf near the entrance in Resident #29's room. d. On 04/22/2024 at 10:39 AM, the Surveyor observed 3 sample size packs triple antibiotic ointment on a shelf near the entrance in Resident #29's room. e. On 04/22/2024 at 10:53 AM, the Surveyor asked Registered Nurse (RN) #1 if the antibiotic cream should be left in the resident's room. RN #1 stated, No. The Surveyor asked RN #1 why this medication should not be left out in the Resident's room. RN #1 stated, Because it's a medication. f. On 04/25/2024 at 10:37 AM, the Surveyor asked the Assistant Director of Nursing (ADON) if any resident in any of cottages were self-administering medications. The ADON stated, No ma'am. The Surveyor asked the ADON if there should be over the counter medications in the Resident's room. The ADON stated, No. 3. On 04/25/2024 at 11:39 AM, the Surveyor was provided a policy titled, Medication Storage in the Facility that documented Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review, the facility failed to ensure staff used proper hand hygiene while passing medication and providing perineal care for 2 (Resident #16 and #25) sampled residents. The findings are: 1. On 04/24/2024 at 07:24 AM, Licensed Practical Nurse (LPN) #3 prepared medications for Resident #16. At 07:32 AM, she put on gloves, administered eye drops, inhaler, and injected scheduled insulin into the abdomen of Resident #16. She then applied cream to Resident #16's arms and hands. At 7:36 AM, LPN #3 discarded the gloves and retrieved a clean pair and, without washing or sanitizing her hands, put on the clean pair of gloves and administered a second dose of eye drops in each eye of Resident #16. a. On 04/25/2024 at 07:59 PM, the Infection Preventionist (IP) was interviewed by telephone and was asked what should a nurse do before changing gloves during medication administration. She asked what the scenario was and was informed the nurse was changing administration routes. The IP then answered, Use hand sanitizer. She was asked why and stated, To prevent contamination. b. A policy provided by the Administrative Assistant on 04/25/2024 titled, Specific Medication Administration Procedures documented, .Policy To administer medications in a safe and effective manner .Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident . 2. Resident #25 had diagnoses of Urinary tract infection and Candidiasis. a. According to the Admission Minimum Data Set with an Assessment Referenced Date of 02/13/2024, Resident #25 scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status and was occasionally incontinent of bowel and bladder. b. A Care Plan with a review date of 02/23/2024 documented Resident #25 required assistance with functional abilities related to muscle weakness, lack of coordination, and fracture to left femur and shaft of right tibia. c. On 04/22/2024 at 12:20 PM, Certified Nursing Assistant (CNA) #2 and #3 provided incontinence care to Resident #25. The Resident's incontinence brief, blue disposable incontinence pad, and sheet were saturated with urine as evidenced by yellow discoloration. Resident #25 had visible skin irritation in the form of reddened excoriation in the areas that contacted the wet brief. When cleaning Resident #25's perineal area, CNA #3 did not properly clean all affected areas of the skin. CNA #2 and #3 did not perform proper hand hygiene or gloves changes after completing incontinence care, after disposing of soiled linens, after applying clean linens, or before applying topical skin barrier cream to the resident's perineal area. d. On 04/22/2024 at 12:37 PM, CNA #3 stated that neither CNA that performed incontinence care for Resident #25 had performed hand sanitation while performing glove changes. CNA #2 confirmed that the Resident's perineal area had been incompletely cleansed, and that soiled gloves had been used to apply the clean sheets, incontinence pad, brief, and topical barrier cream. e. On 04/25/24 at 10:37 AM, the Assistant Director of Nursing (ADON) stated every part of the body that comes in contact with urine should be cleaned, and that it is important to clean all areas that come in contact with urine, so their skin doesn't become irritated, or any skin breakdown occur. The ADON stated that staff should sanitize or wash their hands between glove changes, and that clean items should not be touched with soiled gloves to prevent the spread of infection. f. On 04/25/2024 at 11:39 AM, a policy titled, Hand Hygiene, documented, Perform Hand Hygiene .When .After removing gloves. g. On 04/25/2024 at 11:39 AM, the Surveyor was provided a policy titled, Peri Care Check Off, documented the proper procedure for providing incontinence care, which included to change gloves after touching a soiled area and to change gloves after providing incontinence care to the front of the resident and the back. 48977

Based on interview and record review, the facility failed to ensure a pharmacist's recommendation for the provider to provide an appropriate diagnosis before administering an antipsychotic medication was followed for 1 (Resident #20) sampled resident. The findings are: 1. Resident #20 had diagnoses of Dementia, Major depression, and Delirium due to unknown physiological condition. 2. Resident #20 had an order in place for Zyprexa, which is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder. 3. A Medication Regimen Review (MRR) dated 09/29/2023 documented, A. Consultant Pharmacist .Antipsychotic recommendation . Unnecessary Psychotropic Medication . ZyPREXA Oral Tablet 5 MG (milligram) . Diagnosis: F33.1 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE . Consultant Pharmacist Notes .Consider appropriate diagnosis . a. The Attending Physician/Prescribing Practitioner response was, .Continue current medication regimen with no changes . Clinical rationale and/or documentation for continued need (risk vs. benefit): hospice . b. The Director of Nursing (DON)/Designee response was, MD (medical doctor) response received and accepted .MD Response received and follow up required .The following action has been taken: hospice patient . 4. On 04/25/2024 at 10:37 AM, the Assistant Director of Nursing reported there was no documentation stating that hospice was notified of the recommendations by the Pharmacist dated 09/29/2023. C. On 04/25/2024 at 11:39 AM, the Assistant Director of Nursing stated the facility did not have a policy on unnecessary medications.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services for residents receiving enteral nutrition via Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #23) of 1 sampled resident. The findings are: Resident #35 had diagnoses of sequelae of cerebral infarction, epilepsy, aphasia, and dysphagia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/2024 documented Resident #35 scored 3 (3 indicates severely impaired cognitive skills) on a Staff Assessment for Mental Status (SAMS) and had a PEG tube while a Resident. A Physician ' s Order for Resident #35 documented, Enteral Feed 45 ml (milliliter)/hour for 23 of 24 hours a day, enteral feed every shift flush rate of water (H2O) 60ml/hour, elevate HOB (Head of Bed) 30 to 45 degrees. A Care Plan with a review date of 04/04/2024 documented that Resident #35 had a PEG tube and needs HOB elevated 30 to 45 degrees during tube feeding. On 04/22/2024 at 10:40 AM, the Surveyor observed Certified Nursing Assistant (CNA) #1 at the bedside of Resident #35 providing care. Resident #35's bed was positioned flat, without HOB inclined, while enteral nutrition was infusing at 45 ml/hour with 60ml flush. On 04/22/2024 at 10:45 AM, CNA #1 confirmed it is important to make sure that the infusion has stopped prior to lying the resident flat because the resident could aspirate. On 04/22/2024 at 10:53 AM, Register Nurse (RN) #1 confirmed it was essential to pause the pump providing enteral nutrition before lying the bed flat to prevent aspiration. On 04/25/2024 at 10:37 AM, the Assistant Director of Nursing (ADON) confirmed residents should not be laid flat with enteral nutrition being provided to prevent aspiration, or pneumonia from the aspiration. On 04/25/2024 at 11:39 AM, the ADON voiced that the facility did not have a policy on eternal infusion/feeding.

Based on observation, interview and record review, the facility failed to ensure residents received proper and punctual incontinence care for 1 (Resident #25) sampled resident. The findings are: Resident #25 had diagnoses of Urinary tract infection and Candidiasis. An Admission Minimum Data Set (MDS) with an Assessment Referenced Date (ARD) of 02/13/2024 documented Resident #25 scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and was occasionally incontinent of bowel and bladder. A Care Plan with a review date of 02/23/2024, documented Resident #25 required assistance with functional abilities related to muscle weakness, lack of coordination, and fracture to left femur and shaft of right tibia. On 04/22/2024 at 09:55 AM, the Surveyor noted the odor of urine upon entering Resident #25's room that got stronger upon approach to the resident. Resident #25 was lying in bed with a blue disposable incontinence pad visible underneath the resident's body. On 04/22/2024 at 12:15 PM, the Surveyor observed Resident #25 lying in bed. The Surveyor noted that the Resident's bed was wet, with the blue incontinent pad placed under the resident having a yellow discoloration in a circular pattern. Resident #25 acknowledged the blue disposable incontinence pad underneath the resident was wet and had had an episode of urinary incontinence. On 04/22/2024 at 12:20 PM, Certified Nursing Assistant (CNA) #2 and #3 provided incontinence care to Resident #25. The Resident's incontinence brief, blue disposable incontinence pad, and sheet were saturated with urine as evidenced by yellow discoloration. Resident #25 had visible skin irritation in the form of reddened excoriation in the areas that contacted the wet brief. When cleaning Resident #25's perineal area, CNA #3 did not properly clean all affected areas of the skin. CNA #2 and #3 did not perform proper hand hygiene or gloves changes after completing incontinence care, after disposing of soiled linens, after applying clean linens, or before applying topical skin barrier cream to the resident's perineal area. On 04/22/2024 at 12:37 PM, CNA #3 stated that neither CNA that performed incontinence care for Resident #25 had performed hand sanitation while performing glove changes. CNA #2 confirmed that the resident's perineal area had been incompletely cleansed, and that soiled gloves had been used to apply the clean sheets, incontinence pad, brief, and topical barrier cream. CNA #2 stated that she had last checked the Resident #25 for incontinence at 08:00 AM that morning. On 04/25/2024 at 10:37 AM, the Assistant Director of Nursing (ADON) stated every part of the body that comes in contact with urine should be cleaned when providing incontinence care, and that it is important to clean all areas that come in contact with urine, so their skin doesn't become irritated, or any skin breakdown occurs. The ADON stated that improper incontinence care could lead to a urinary tract infection, that staff should sanitize or wash hands between glove changes, and that clean items should not be touched with soiled gloves to prevent the spread of infection. On 04/25/2024 at 11:39 AM, a policy titled Hand Hygiene documented Perform Hand Hygiene .When .After removing gloves. On 04/25/2024 at 11:39 AM, the Surveyor was provided a policy titled Peri Care Check Off that documented the proper procedure for providing incontinence care, which included to change gloves after touching a soiled area and to change gloves after providing incontinence care to the front of the resident and the back.

Based on observation, interview and record review, the facility failed to ensure resident restrooms were cleaned to promote a clean and sanitary environment for 1 (Resident #43) of 1 sampled resident who used the bathroom in their room. The findings are: 1. Resident #43 had diagnoses of weakness and constipation as documented on an order summary. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/2024 documented the resident had a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact) and required substantial/maximal assistance with toileting hygiene. b. A Care Plan dated 02/16/2024 documented Resident #43 required assistance with some functional abilities related to weakness and requires assistance of one staff with toileting hygiene. c. On 04/22/2024 at 12:55 PM, Resident #43's toilet had brown stains on the inside and outside of the toilet bowl. d. On 04/23/2024 at 03:38 PM, Resident #43's toilet had brown stains on the inside and outside of the toilet bowl. e. On 04/25/2024 at 06:00 PM, Resident #43's toilet had a brown substance in front of the toilet bowl just below the seat and on the back of the seat. f. On 04/25/2024 at 07:10 PM, Certified Nursing Assistant (CNA) #11 stated that the CNAs were responsible for cleaning the resident's rooms and stated, On bath days, the CNAs goes in the room for deep cleaning. CNA #11 stated Resident #43's bath days were Tuesday and Thursday. g. On 04/25/2024, the Administrative Assistant stated they did not have a policy on cleaning resident rooms.

Based on observation, interview and record review, the facility failed to ensure medications were not self-administered without a physician's order, and the interdisciplinary team (IDT) assessed residents to determine self-administration of medications was safe for 1 (Resident #33) of 1 sampled resident. The findings are: On 04/22/2024 at 11:44 AM, a bottle of Nystatin-Triamcinolone Cream was found in Resident #33's bathroom. Resident #33 stated that the resident applies the cream to the resident because of where it is located. On 04/24/2024 at 09:19 AM, a bottle of Nystatin-Triamcinolone Cream was found in Resident #33's bathroom. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 documented Resident #33 scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). Resident #33's Care Plan dated 04/01/2024, did not identify the resident as able or assessed to self-administer medications. The Medication Administration Record (MAR) dated April 2024 documented that Resident #33 had been diagnosed with candidiasis (a fungal infection caused by a yeast (a type of fungus) called Candida) and had a Physician's Order for Nystatin-Triamcinolone Cream to be applied to the abdomen, the groin and under the breasts topically every 24 hours as needed for itching/redness. On 04/24/2024 at 8:52 AM, Licensed Practical Nurse (LPN) #3 stated there were no residents that self-administered medications, and that she was unaware of any resident assessed for self-administration of medications. LPN #3 stated the reason it was important for residents to be assessed for self-administration of medications was to make sure they can actually take the medicine and that it was the right mediation. LPN #3 stated that any resident who had been assessed and approved to self-administer medications would have those medications stored in a locked cabinet in the resident's room. On 04/24/2024 at 09:07 AM, the Director of Nursing (DON) stated there were no residents that self-administered medications, and that there had been no resident assessed for self-administration of medications in over a year. The DON stated the reason it was important for residents to be assessed for self-administration of medications was to make sure they know how to safely do it, to not over or under medicate, and to not allow another resident to have access to their medication. On 04/24/2024 at 9:20 AM, the DON asked Resident #33 where the medicating cream had been obtained. Resident #33 stated one of the nurses left it for the resident to self-administer. The DON explained to the resident that medication cannot be kept at bedside and the resident voiced understanding. On 04/24/2024 at 09:44 AM, the DON was unable to produce a policy for resident self-administration of medications, or a self-administration form.

Based on observation, record review, and interview, the facility failed to ensure safety and supervision to prevent elopement from the secure unit for 1 (Residents #1) of 3 (Resident #1, #2, #3) sampled residents. This failed practice resulted in Past non-compliance at Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy on 07/12/2023 at 2:00 PM. The findings are: 1. Resident #1 was admitted to the secure unit in the facility on 02/24/2023 with diagnosis of dementia, anxiety disorder, and chronic obstructive pulmonary disease and repeated falls. According to The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/2023, Resident #1 had a BIMS (Brief Interview for Mental Status) of 03 (indicates severe impairment) and required supervision for ambulation on unit and off unit. a. The Plan of Care with an initiated date of 2/24/23 showed, Resident #1 was an elopement risk/wanderer related to history of wandering. Interventions included resident to reside in a secure cottage, and staff to observe for any changes in wandering or exit seeking behaviors. b. Review of the Wandering Risk Scale assessment dated [DATE] revealed Resident #1 had a history of wandering and resides in the secure unit. The Resident was scored as a high risk for wandering. c. Review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term care Facilities (Form DMS-762) noted on 7/4/23 Resident #1 left the facility without supervision. The document noted the resident was last observed by staff at approximately 12:40 PM in the day room, and at 12:30 PM according to the report, a man saw the resident and called the sheriff's office at 12:43 PM. The resident was taken by ambulance from the apartment complex area, where he was found, to the local hospital for evaluation. d. Witness statements from the DMS-762 revealed Certified Nursing Assistant (CNA) #4 last saw Resident #1 at 12:38 PM and did not realize he was missing until 12:45 PM. CNA #1 noted the last time she saw Resident #1 was approximately 12:36 PM and noted the resident was walking around in the cottage. e. On 7/11/2023 at 1:05 PM interview with the administrator who stated, Resident #1 went to the apartments, which are next to the facility, through the woods by a small trail. She stated the resident went out with family members from the locked/secured unit. She further stated, Resident #1 looks fine, and you would not know that he must be supervised just to look, he is able to walk without hands on assist, he just needs supervision. The administrator stated the secure code was in place, but the staff had given it out to the families because the families had to wait for staff and it takes a bit for them to get to the door. She further stated the code will be changed, and will not be given to the families, they will have to wait for staff to let them in. f. On 7/11/2023 at 1:45 PM observed all exterior doors in the secure cottage. The front entrance door, the back entrance that leads to a fenced in yard (library area), the side door by the laundry room entrance and the side door by the sprinkler system entrance, both side doors that face the wooded area (Resident #1 exited from) have the secure code entrance-exit locking system. There were no sounding alarms for any of the doors in and out of the locked cottage, there was no signage noted on the doorways alerting visitors or staff to not allow residents to follow them out of the secure unit. g. On 7/11/2023 at 4:00 PM observed the trail area from the facility cottage grounds to the apartment complex that resident #1 walked through on 7/4/2023. The trail appeared to be [NAME] red dirt with pine straw on the ground, the trail was 20 to 22 feet long and 3-4 feet wide with large, tall pine trees on both sides of the trail area. There was muddy water along the trail. The apartment complex had multiple 2 story buildings and a concrete walk path around into the car parking lot area that was surrounded by the buildings. h. On 7/12/2023 at 7:30AM the surveyor walked up to the secure unit to enter. A staff member exited through the front entrance, and offered the surveyor the code to enter the cottage. i. On 7/12/2023 at 9:55AM interview with Licensed Practical Nurse (LPN) #1 who stated on 7/4/23 she received a call from the ambulance service requesting Resident #1's Date of Birth, and stated they had the Resident in route to the hospital. She stated from her understanding the CNA's in the secure cottage had been looking for Resident #1 for about 10 minutes and had not called to notify her because they wanted to make sure the Resident was not just in a room somewhere. LPN #1 stated, I think the Resident followed the family of one of the other residents out when they left, Resident #1 can walk very good and really doesn't look like a nursing home resident. j. On 7/13/2023 at 9:40AM the surveyor asked CNA #3, who had the code to the secure cottage entrance/exit front door on 7/4/2023? CNA #3 stated, the staff of course, and some of the families that come regularly. She stated there were two families visiting on 7/4/23, one left at 12:30 PM and the other left about 12:40 PM. She stated the doors have not malfunctioned in the past, and always lock and stated she thinks the resident walked out with one of the families. She stated the Resident has not attempted to exit in the past, and stated the resident does go out to smoke. k. On 7/13/2023 at 10:20 AM interview with the Director of Nursing (DON) revealed the LPN working on the day of the elopement believed the resident exited with the visitors. She stated the staff and the families who visit regularly have the door code, and further stated the staff provided the code to the family members. The DON confirmed there was no signage on the exit doors related to not letting the residents out of the door. l. Review of the website www.timeanddate.com/weather, accessed on 7/13/23 revealed the temperature for 7/4/23 at 12:00 PM to be 90 degrees and partly sunny, with humidity at 61 percent. m. On 7/13/2023 at 10:30AM review of policy titled, Missing Resident/Elopement Protocols, no date of. The policy stated, .It is the policy of the facility to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy of the facility to implement its elopement protocols immediately to locate the resident in a timely manner. 2. The facility implemented the following to correct the non-compliance: a. On 7/4/2023 Abuse and neglect training was completed in the secure cottage. b. On 7/4/2023 Resident #1 was placed on a 48-hour l -on 1supervision until the secure cottage door code could be changed. Only staff will have the secure door code. Staff will let visitors in and out. Staff will be required to stand by the door to assure they hear door closure clicks and locks. Staff must put in secure key code to allow any entrance to the secure cottage or exit from the secure cottage and the staff have been instructed not to give out the code to visitors. c. On 7/4/2023 All staff on all shifts will review the care plans, and will follow the care plans. d. On 7/4/2023 Inservice on Elopement / missing resident and protocols. e. On 7/4/2023 the Maintenance Director checked all locks and keypad lock number was changed. f. On 7/4/2023 a plan for a fence to be placed around the property. On 7-11-2023 at 1:30 PM observed maintenance staff with heavy equipment in the area of the planned fence, clearing small trees and dirt for construction to begin. g. On 7-12-23 at 8:30 AM the Administrator stated the facility has ordered and will be putting low sounding alarms on all the doors to the secure unit that will sound if the door is open for a specified length of time to alert the staff.

Based on observation, interview, and record review, the facility failed to provide service to maintain appropriate sleep hygiene for 2 (Residents #11 and #67) sampled residents who use Continuous Positive Airway Pressure (CPAP). The findings are: 1. Resident #11 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23 documented a score of 14 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS), required one-person physical assist with bathing, supervision with locomotion on and off unit, toileting, dressing, personal hygiene and was independent with bed mobility and transfers. a. The Care Plan with a revision date of 05/11/22 documented, .Resident #11 is at risk for altered respiratory status, complications/SOB [Shortness of Breath] r/t [related to] COPD and Respiratory Failure .CPAP @ [at] HS as ordered . b. The Physician's Order with a start date of 02/16/23 documented, .Auto BPAP [Bilevel Positive Airway Pressure] to be worn at bedtime IPAP [Inspiratory Positive Airway Pressure], setting 18-24, EPAP [Expiratory Positive Airway Pressure] 14-20 at bedtime .Change and Date: Auto BiPAP storage bag. Wash Auto BiPAP mask with soap and water. Every day shift every Sat [Saturday] . c. On 05/01/23 at 1:56 PM, Resident #11 was sitting in his recliner in his room with the Oxygen via nasal cannula set at 3 liters per minute He stated, I need my CPAP fixed, I can't wear it, the hoses are too big for the mask. d. On 05/02/23 at 9:33 AM., Resident #11 was in his room in his recliner. He asked, Did you find out anything about my CPAP? e. On 05/03/23 at 2:30 PM., the Surveyor asked the Director of Nursing (DON), Do you know why Resident #11 is not wearing his CPAP at night? The DON replied, He has anxiety and does not like the feeling he gets when it is too tight, the resident says it's too tight and needs a larger one. 2. Resident #67 had a diagnosis of Obstructive Sleep Apnea. The Quarterly MDS with an ARD of 02/26/23 documented of 15 (13-15 indicates cognitively intact) on a BIMS, required one-person physical assist with dressing, grooming, and bathing and supervision with transfers. a. The Care Plan with an initiation date of 06/11/21 documented, .Resident #67 is at risk for altered respiratory status/difficulty breathing .CPAP machine to be worn @ HS PRN [at bedtime as needed]. b. The Physician's Orders with a start date of 11/18/22 documented, .CPAP to be worn at bedtime .CPAP to be cleaned weekly-must take apart and clean reservoir .Clean Mask. Change and date: CPAP storage bag. Wash CPAP mask with soap and water. Every day shift every Sat . c. On 05/01/23 at 1:43 PM., Resident #67's CPAP mask was connected to the hoses on the CPAP machine, un-bagged and lying on his bed. d. On 05/02/23 at 9:09 AM., Resident #67's CPAP mask was lying un-bagged in the seat of the recliner next to his bed. e. On 05/04/23 at 1:15 PM., the Surveyor asked the DON for a policy on oxygen and respiratory equipment storage. By 2:30 PM, a policy had not been provided.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards to prevent the worsening of a skin condition for 1 (Resident #11) sampled resident who had a non-pressure related skin condition and failed to provide services to prevent the worsening of a contracture for 1 (Resident #42) sampled resident who required a hand roll. The findings are: 1. Resident #11 had a diagnosis of Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremities. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23 received a score of 14 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS). Requires one-person physical assist with bathing, supervision with locomotion on and off unit, toileting, dressing, personal hygiene and is independent with bed mobility and transfers. a. The Care Plan with a revision date of 05/11/22 documented, .Resident #11 is at risk for Impaired Skin Integrity .Report any skin concerns to nurse .Unna boot to bil [Bilateral] legs . b. The Progress Note dated 04/12/23 documented, . Wound to R [Right] shin resolved. No open area or signs of infection present .New order to d/c [discontinue] treatment to R shin . c. The review of the Active Orders with a date of 05/03/23 showed no current treatment ordered for Resident 11's lower legs. d. On 05/01/23 at 1:56 PM., Resident #11 was sitting in his room in his recliner. He was wearing short pants with his legs exposed. His bilateral lower legs were discolored, with each having scattered open areas along the front of both legs, and a red to clear drainage going down both of them. e. On 05/02/23 at 9:33 AM., Resident #11 was sitting in his recliner in his room with his feet elevated. His lower legs were exposed with dried drainage on both of them. f. On 05/03/23 at 1:30 PM., the Surveyor asked Licensed Practical Nurse (LPN) #1 Is Resident #11 receiving a treatment to his lower legs? LPN #1 stated, He was but they are healed, so not right now. The Surveyor stated, He has open areas on both lower legs. LPN #1 stated, I will have to check his legs and call the provider. g. On 05/03/23 at 3:00 PM., the Director of Nursing (DON) notified the Surveyor that LPN #1 had contacted the provider and received an order for Resident #11's lower legs which she had already done. h. On 05/04/23 at 1:15 PM., the DON stated, There was not a policy for wound care, and it was according to the Physician's Order. 2. Resident #42 had a diagnosis of Cerebral Vascular Accident (CVA) and Hemiplegia. The MDS with an ARD of 02/26/23 documented a score of 15(13-15 indicates cognitively intact) on a BIMS. Required limited assistance of one person for transfers, dressing, toilet use and personal hygiene and has limited range of motion upper and lower extremities on one side. a. The Care Plan with a revision date of 02/26/20 documented, .Resident #42 has an Activity of Daily Living (ADL) self-care performance deficit, .requires supervision to limited assistance with ADLs.is non-ambulatory and has weakness to left side r/t [related to] Cerebral Infarction .Resident #42 uses a wheelchair for mobility .hand roll to left hand . b. On 05/02/23 at 9:03 AM., Resident #42 was sitting outside in his wheelchair. His left-hand was slacked at the side in a contracture, but not in a hand roll. At 9:20 AM, the Surveyor asked Resident #42, Do you normally wear a hand roll in your left hand? Resident #42 stated, Yes, and an arm brace too. The Surveyor asked, Do you apply them yourself? Resident #42 stated, They [Certified Nursing Assistants] help me with them. c. On 05/02/23 at 3:40 PM., Resident #42 was outside in his wheelchair. His left arm was slacked at the side with his hand in his wheelchair seat beside his leg, no hand roll was in place. d. On 05/04/23 at 1:15 PM., the DON stated, We do not have a specific policy for hand rolls and splints, they are applied according to the Physician's Orders.

Based on interview and record review, the facility failed to ensure that residents who experienced a significant change in status had a comprehensive assessment completed within 14 days of the facility determining that there had been a significant change for 2 (Residents #26, and #86) of 24 (#2, #11, #14, #26, #28, #29, #42, #43, #51, #57, #61, #63, #67, #69, #72, #73, #75, #77, #82, #85, #86, #87, #138, and #191) sampled residents who relied on the facility for accurate Minimum Data Set (MDS) documentation. The findings are: 1. Resident #26 had diagnoses of Systemic Lupus Erythematosus, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left Dominant Side, and Primary generalized Osteoarthritis. The Quarterly MDS with an Assessment Reference Date (ARD) of 02/21/23 documented a score of 9 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS). a. The Quarterly MDS with an ARD of 11/21/22 documented the following under Section G, Subsection G0110. Activities of Daily Living (ADL) Assistance: i. Bed mobility required limited assistance with one person physically assisting. ii. Transfer required extensive assistance with one person physically assisting. iii. Eating required supervision with setup help only. iv. Toileting required extensive assistance with two or more people physically assisting. b. The Quarterly MDS with an ARD of 02/21/23 documented the following under Section G, Subsection G0110. ADL Assistance: i. Bed mobility required limited assistance with one person physically assisting. ii. Transfer required extensive assistance with two or more people physically assisting. iii. Eating required supervision with setup help only. iv. Toileting required extensive assistance with one person physically assisting. c. On 05/04/23 at 8:05 AM., the Surveyor asked the MDS Coordinator to navigate to Resident #26's chart in [Facility Computer Software] and verify that there were two or more changes in her condition. The MDS Coordinator stated, Mmhmm there is. Sometimes she gets better or worse, so I just watch it and go back and change it if something changes. She's got another assessment coming up soon. The Surveyor asked if a Significant Change MDS should be performed if there were two or more changes in a resident's condition. The MDS Coordinator stated, I think it's three changes before you have to do another assessment. The Surveyor informed her that Appendix PP in the State Operations Manual currently required a Significant Change MDS to be performed if there were two or more changes in the resident's status. The MDS Coordinator stated, I didn't know that. 2. Resident #86 had diagnoses of Alzheimer's disease, Non-ST-Elevation Myocardial Infarction, and Type 2 Diabetes Mellitus. The Quarterly MDS with an ARD of 01/20/23 documented a score of 3 (3 indicates severely impaired) on a Staff Assessment for Mental Status (SAMS). a. The Quarterly MDS with an ARD of 10/20/22 documented the following under Section G, Subsection G0110. ADL Assistance: i. Bed mobility was independent with no setup or physical help from staff. ii. Transfer was independent with no setup or physical help from staff. iii. Eating required supervision with setup help only. iv. Toileting required supervision with setup help only. b. The Quarterly MDS with an ARD of 01/20/23 documented the following under Section G, Subsection G0110. ADL Assistance: i. Bed mobility required supervision with setup help only. ii. Transfer required limited assistance with one person physically assisting. iii. Eating required supervision with setup help only. iv. Toileting required limited assistance with one person physically assisting. c. On 05/04/23 at 8:05 AM., the Surveyor asked the MDS Coordinator to navigate to Resident #86's chart in [Facility Computer Software] and verify that there were three changes in the resident's condition. The MDS Coordinator stated, Yes. 3. The State Operations Manual Appendix PP documented, .A Significant Change in Status MDS is required when: .A resident experience a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS [Center for Medicare and Medicaid Services]-required MDS) .

Based on interview and record review, the facility failed to ensure supervision was provided for residents who were an elopement risk for 1 (Resident #1) of 3 (Resident #1, #2, and #3) sampled residents. The findings are: 1. Resident #1 had a diagnosis of [CONDITION(S)], Psychotic Disturbance, Mood Disturbance and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/02/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with set up with locomotion on and off the unit and required one person limited physical assistance with transfers. a. The Care Plan with an initiated date of 9/3/22 documented, .[Resident #1] is at risk for elopement risk/wanderer r/t [related to] attempt to leave the facility .Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . b. The Incident Report dated 9/13/22 documented, .On 9/13/22 it was reported to the Administrator that [Resident #1] from Cottage 2 . left front porch of the cottage and walked to [Facility] that is 0.2 miles from the facility. Administrator immediately took the facility van to the end of the facility drive to escort the elder back to the secure cottage. CNA [Certified Nursing Assistant] also went on the facility van with Administrator . c. On 9/29/22 at 2:17 PM, the Surveyor asked CNA #5, Has [Resident #1] ever showed any signs of wondering or elopement? She stated, I wouldn't say elopement. She walked down sidewalks one day and she would say she's going to the mountain. The Surveyor asked, Were you here the day [Resident #1] eloped? She stated, Yes, I came to work she was outside. About 4:15 PM, another resident started choking, and after that I walked to the dining room. At 4:20 PM, we got a call saying one of our residents was missing. The admissions worker came told us. Someone had called the front office. The Administrator picked her up. I was told she went towards the woods by the garbage cans. The Surveyor asked, How do you provide supervision to residents to keep them from eloping? She stated, Watch them every 15 minutes, and talk to them if they try to leave. d. On 9/29/22 at 3:12 PM, during a phone interview with CNA #6 (a previous employee), the Surveyor asked, Did you see [Resident #1] when she left the facility? She stated, I don't stay far from the nursing home. I saw her walking and I called out there, and they came and picked her up in the van. e. On 09/30/22 at 10:42 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Are residents allowed to go outside without supervision? She stated, To my understanding the aids have to check on them every 15 minutes. The Surveyor asked, How do you provide supervision to residents to keep them from eloping? She stated, Making sure the aids are making their rounds when they are supposed to. f. On 9/30/22 at 11:41 AM, the Surveyor asked CNA #1, How do you provide supervision to residents to keep them from eloping? She stated, Watch them. g. On 9/30/22 at 12:10 PM, the Surveyor asked the Administrator, How do you provide supervision to residents to keep them from eloping? She stated, The staff assist the ones that are out on the porch.

Based on interview and record review, the facility failed to ensure an unwitnessed fall was promptly and thoroughly investigated to rule out potential abuse or neglect and facilitate the ability to implement protective measures to prevent further potential injury or 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who had had a fall. The findings are: 1. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/02/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with set up with locomotion on and off the unit and required one person limited physical assistance with transfers. a. The Care Plan with an initiated date of 9/3/22 documented, .[Resident #1] is at risk for elopement risk/wanderer r/t [related to] attempt to leave the facility .Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . b. The Incident Report dated 9/20/22 documented, .Fall Witnessed .Elder was exit seeking. Peer was upset from all the noise she was making and attempted to kick her. Peer lost her shoe and elder tripped over it .Agencies/People Notified .No Notifications found .9/22/22 ADON [Assistant Director of Nursing] was running her report that includes progress notes for the last 24 hours . [Resident #1] told staff she had been kicked by another person and her knee is hurting . c. The Witness Statement completed by Licensed practical Nurse (LPN) #3 dated 9/22/22 documented, .CNA [Certified Nursing Assistant] said resident had C/O [complaint of] left knee and left hip pain. Nurse ask [asked] resident if she could look at her left knee and left hip. Nurse viewed a bruise and lump on resident left knee. Nurse asked resident what happened, resident stated that a tall white women kicked her last night but couldn't remember who the lady was. When evening CNA came in, she reported that resident 102 and resident 108 was at the front door and both pulling at walker, both fell . Nurse asked CNA did they report it to the night nurse. CNA stated that the night nurse was there . d. The Witness Statement dated 9/23/22 documented, .Both elders where in the common area when they bumped into each other causing them both to fall. The nurse and the co-worker saw the incident . e. On 9/30/22 at 10:42 AM, the Surveyor asked LPN #2, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed? She stated, Immediately. f. On 9/30/22 at 11:11 AM, the Surveyor asked CNA #3, Can you tell me about the incident where [Resident #1] had a fall? She stated, I took her outside and she told me her knee was hurting when I was getting her up. That's when she told me that someone had kicked her. [CNA #4] checked her and said her knee was swollen and had a bruise on it. I asked [LPN #3] if it was in the notes about her knee. [LPN #3] said no there wasn't anything in the notes. [Resident #1] said a white women kicked her, then she said it was a black woman. Her story kept changing. g. On 9/30/22 at 11:41 AM, the Surveyor asked CNA #1, Can you tell me about the incident where [Resident #1] had a fall? She stated, I was in the kitchen and when I turned around, her and another resident were on the floor. They both were on the floor. The nurse was in there and [CNA #2] was on the computer charting. [LPN #1] was passing her meds. We picked them up and the nurse asked if she was OK. The next day they said the lady on one had a knot on her leg. I didn't see what caused it. I just saw they both were on the floor. The Surveyor asked, Did the nurse ask you to fill out a witness statement that night? She stated, No she didn't. The Surveyor asked, Did you see anyone kick her after she fell ? She stated, No ma'am. The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation be started? She stated, Immediately. The Surveyor asked, Did the nurse do anything after the fall? She stated, No. h. On 9/30/22 at 12:04 PM, the Surveyor asked the Director of Nursing (DON), Can you tell me about the incident where [Resident #1] had a fall? She stated, It was reported to me on the 9/22/22. They said her and another resident had a moment and they both fell . The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation started? She stated, Immediately. The Surveyor asked, Can you tell me why an investigation didn't start until 9/22/22. She stated, That's when we were made aware of the situation. i. On 9/30/22 at 12:10 PM, the Surveyor asked the Administrator, Can you tell me about the incident where [Resident #1] had a fall? She stated, I was called that they were doing their morning audit. They came across a note that an elder had been kicked. The staff took her to her room, and it was a bruise on her knee. A staff told us they had a fall. The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation started? She stated, Immediately, I started it immediately, as soon as I was aware. j. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation, and Reporting, provided by the Administrator on 9/30/22 at 12:30 PM documented, .Identification and investigation . The administrator or Administrator's designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident occurred that is defined as abuse, neglect, or misappropriation by state law .The nursing facility shall take all necessary steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress .

Based on interview and record review, the facility failed to ensure an unwitnessed fall with an accusation of being kicked was reported to the Administrator within 2 hours, which resulted in delays in initiating an investigation to rule out possible abuse/neglect and in reporting the injury to the Office of Long Term Care (OLTC) and other agencies in accordance with state law for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who had had a fall. The findings are: 1. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/02/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with set up with locomotion on and off the unit and required one person limited physical assistance with transfers. a. The Care Plan with an initiated date of 9/3/22 documented, .[Resident #1] is at risk for elopement risk/wanderer r/t [related to] attempt to leave the facility .Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . b. The Incident Report dated 9/20/22 documented, .Fall Witnessed .Elder was exit seeking. Peer was upset from all the noise she was making and attempted to kick her. Peer lost her shoe and elder tripped over it .Agencies/People Notified .No Notifications found .9/22/22 ADON [Assistant Director of Nursing] was running her report that includes progress notes for the last 24 hours . [Resident #1] told staff she had been kicked by another person and her knee is hurting . c. The Witness Statement completed by Licensed practical Nurse (LPN) #3 dated 9/22/22 documented, .CNA [Certified Nursing Assistant] said resident had C/O [complaint of] left knee and left hip pain. Nurse ask [asked] resident if she could look at her left knee and left hip. Nurse viewed a bruise and lump on resident left knee. Nurse asked resident what happened, resident stated that a tall white women kicked her last night but couldn't remember who the lady was. When evening CNA came in, she reported that resident 102 and resident 108 was at the front door and both pulling at walker, both fell . Nurse asked CNA did they report it to the night nurse. CNA stated that the night nurse was there . d. The Witness Statement dated 9/23/22 documented, .Both elders where in the common area when they bumped into each other causing them both to fall. The nurse and the co-worker saw the incident . e. On 9/30/22 at 10:42 AM, the Surveyor asked LPN #2, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed? She stated, Immediately. f. On 9/30/22 at 11:11 AM, the Surveyor asked CNA #3, Can you tell me about the incident where [Resident #1] had a fall? She stated, I took her outside and she told me her knee was hurting when I was getting her up. That's when she told me that someone had kicked her. [CNA #4] checked her and said her knee was swollen and had a bruise on it. I asked [LPN #3] if it was in the notes about her knee. [LPN #3] said no there wasn't anything in the notes. [Resident #1] said a white women kicked her, then she said it was a black woman. Her story kept changing. g. On 9/30/22 at 11:41 AM, the Surveyor asked CNA #1, Can you tell me about the incident where [Resident #1] had a fall? She stated, I was in the kitchen and when I turned around, her and another resident were on the floor. They both were on the floor. The nurse was in there and [CNA #2] was on the computer charting. [LPN #1] was passing her meds. We picked them up and the nurse asked if she was OK. The next day they said the lady on one had a knot on her leg. I didn't see what caused it. I just saw they both were on the floor. The Surveyor asked, Did the nurse ask you to fill out a witness statement that night? She stated, No she didn't. The Surveyor asked, Did you see anyone kick her after she fell ? She stated, No ma'am. The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation be started? She stated, Immediately. The Surveyor asked, Did the nurse do anything after the fall? She stated, No. h. On 9/30/22 at 12:04 PM, the Surveyor asked the Director of Nursing (DON), Can you tell me about the incident where [Resident #1] had a fall? She stated, It was reported to me on the 9/22/22. They said her and another resident had a moment and they both fell . The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation started? She stated, Immediately. The Surveyor asked, Can you tell me why an investigation didn't start until 9/22/22. She stated, That's when we were made aware of the situation. i. On 9/30/22 at 12:10 PM, the Surveyor asked the Administrator, Can you tell me about the incident where [Resident #1] had a fall? She stated, I was called that they were doing their morning audit. They came across a note that an elder had been kicked. The staff took her to her room, and it was a bruise on her knee. A staff told us they had a fall. The Surveyor asked, If a resident had a fall, and they reported that they were kicked, when should an incident report be completed, and an investigation started? She stated, Immediately, I started it immediately, as soon as I was aware. j. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation, and Reporting, provided by the Administrator on 9/30/22 at 12:30 PM documented, .Immediate reporting: All incidents of alleged or suspected Resident/Elder maltreatment, including neglect, or abuse, and misappropriation of Resident/Elder property must be reported immediately to the administrator or the administrator's Designee by a facility staff member or their immediate supervisor. The administrator, or their designee, shall conduct a preliminary review of the circumstances to determine if an allegation of abuse or neglect exists. Following this determination, the administrator or their designee will initiate actions to report incidents as required by State law or regulation, including the Office of Long-Term Care as well as the registry and/or licensing board .

Based on interview and record review, the facility failed to ensure interventions were put in place to prevent the potential for further abuse for 1 (Resident #1) of 3 (Resident #1, #2, #3) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/08/22 documented the resident scored 00 (00-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required limited one-person physical assistance with personal hygiene and was independent with walking and transfers. a. The Care Plan with a revision date of 6/14/22 documented, .Resident #1] has a behavior at times such as refusing care .explain all procedures to [Resident #1] before starting . The Care Plan did not address interventions for nail care. b. The Incident Report dated 7/11/22 documented, .At approximately 3:00 PM 7/11/22 the ADON [Assistant Director of Nursing] was notified by [CNA (Certified Nursing Assistant) #2] that she felt a concern with the way staff were cutting [Resident #1's] fingernails. [CNA #2] stated she was on the porch when she heard someone yelling and when she looked through the window [she] saw [CNA #1] cutting residents nails . Date and time reported to OLTC [Office of Long Term Care]: 7/14/22 . c. The Witness Statement completed by CNA #1 dated 7/11/22 at 3:04 PM documented, . Elder [has] been up all day wandering in and out of room braking [breaking] the blinds to windows. I went in elders' room, and she was trying to brake some more blinds. I asked her what she was doing and had a shoe grabing [grabbing] to blinds bending them. Tryed [tried] to stop her she grabbed my arm with long nails and started twisting and scratching. I pulled my arm back she got mad and walked off. I cleaned and put a band-aid on my hand then I went to get some nail clippers and waited until she was in the living room got her to sit down told her I was going to clip her nails. She was fine until she noticed I was cutting them short enough not to scratch anybody including herself. Then was upset and yelling, scratching, kicking, and trying to bite. Nurse told her she can't bite she said, Yes I can. So, nurse and other worker was trying to distract her and talk to her. I had my leg on top of hers while sitting next to her. I have been kneed in face by elder. Before she was yelling and trying to bite . Other staff member was outside come in and told us the other staff members and nurse that that was abuse. I told her her nails were sharp and very long and needed to be cut . d. On 9/01/22 at 12:52 PM, the Surveyor asked the Administrator, When you are made aware of an allegation of abuse when should it be reported to Office of Long Term Care? She stated, By 11:00 AM the following day. The Surveyor asked, Can you tell me why an allegation of abuse wasn't reported to OLTC until 7/14/22? She stated, The staff talked to the ADON, and she was asked to do a witness statement. The Surveyor asked, What is considered a restraint? She stated, Anything holding a part of the body down, seat belt, chemical. The Surveyor asked, Should staff hold a resident down if they are refusing to get their nails clipped? She stated, No ma'am. The Surveyor asked, What residents did you interview to see if they had been abused? She stated, Nobody had a BIMS high enough to be interviewed. The Surveyor asked, What interventions did you put in place to prevent this incident from happening again? She stated, Sent [CNA #1] home, and skin assessments on everybody in the building. e. On 9/02/22 at 10:20 AM, the Surveyor asked CNA #1, Can you tell me what happened when you were cutting [Resident #1's] nails? She stated, [Resident #1] has Dementia, and she doesn't like getting her nails cut. She scratches other staff and herself. She had a bunch of funkiness under her nail. She was fine until I cut the first one. When I cut the first one, she got very upset. She got to kicking and sound like she was talking in tongue. The nurse tried to calm her down. She was trying to kick, bite and scratch. The Surveyor asked, Did you continue to cut her nails after she was kicking, biting and scratching? She stated, Yes. The Surveyor asked, What are the types of abuse? She stated, Involuntary isolation, misappropriation of funds, sexual, physical, and verbal. The Surveyor asked, At any time did you have to use a physical restraint while you were cutting her nails? She stated, The only thing I did was block her knees from kneeing me in the face. She has kneed me before. The Surveyor asked, At any time did you put your leg over her leg to keep her from kicking? She stated, That was a block. She could freely move her leg just not up into my face. The Surveyor asked, If a resident is refusing care and becoming combative and you are trying to provide nail care, what should you have done? She stated, Let the nurse know. The Surveyor asked, Should you have continued to do [Resident #1's] nails if she was refusing and kicking? She stated, I would say no, but [Resident #1] refuses every single time. The Surveyor asked, What could happen if you are trying to do nail care, and a resident is combative? She stated, They could get riled up and they could get hurt. The Surveyor asked, What interventions did the facility put in place to keep this incident from happening again when [Resident #1] receives nail care? She stated, I absolutely have no idea. I was suspended for three days and came back. They said they didn't find anything and that was it. f. On 9/02/22 at 10:46 AM, the Surveyor asked CNA #2, Do you have knowledge of the alleged abuse with [Resident #1]? She stated, Yes, I was outside, and I heard her scream. I looked in the window and saw the [CNA #1] across the resident's lap to keep her from moving. [CNA #3] and [LPN #1] the nurse was standing by. I came inside the building after gathering residents from outside. I told [CNA #1] she shouldn't do that because that's a form of abuse. She said so report me, and I did just that. I reported her to the treatment nurse. She was off so I walked to the office. I saw the Social Worker and she told me to talk to the charge nurse. I told the ADON, the charge nurse. She's the RN [Registered Nurse], after telling her she needed a statement. I wrote the statement, but I didn't turn it in until 2 days later. I wanted to make sure I had everything correct, but I did let them know what had happened. That was pretty much the bulk of it. g. On 9/02/22 at 11:30 AM, the Surveyor asked the DON, Did you conduct any interviews with any residents related to the alleged abuse and identify the circumstances of what occurred prior to, during and after the alleged abuse? She stated, I didn't, I believe the ADON did I'm not sure I know. The Surveyor asked, Does the care plan identify interventions to address any behaviors of the alleged perpetrator? She stated, I wasn't here the day all that happened. The Surveyor asked, Was the care plan revised after the incident? She stated, I don't do care plans. The Surveyor asked, What documented interventions did you put in place to keep this incident from happening again? She stated, They educated the staff on letting her set the pace of things. The Surveyor asked, Who is responsible for supervising and monitoring the delivery of care at the bedside? She stated, The floor nurses. The Surveyor asked, If a resident is refusing care and becoming combative and you are trying to provide nail care, what should you have done? She stated, Walk away. The Surveyor asked, If a staff is putting their legs over a resident's leg to prevent movement is that considered a restraint? She stated, Yes. h. On 9/02/22 at 11:45 PM, the Surveyor asked the MDS Coordinator, Was the care plan revised after the incident with [Resident #1]?' She stated, No ma'am. The Surveyor asked, Did anyone inform you that the incident had happened. She stated, No ma'am. i. On 9/02/22 at 11:53 AM, during a phone interview with Licensed Practical Nurse (LPN #1), the Surveyor asked, Did you have knowledge of the alleged abuse with [Resident #1]? She stated, Yes, I was there. [Resident #1] can be combative. Her nails can be very, very long. [CNA #1] had her leg over [Resident #1's] leg just to keep her from kneeing her in the face because she had done that before. I was in my office when it started, and I heard her screaming. I was trying to console her. Another CNA named [CNA #3] was also there trying to console [Resident #1]. The Surveyor asked, Is it considered a restraint if a staff holds a resident down to prevent movement? She stated, Yes. The Surveyor asked, Was there an order to restrain her? She stated, Oh no ma'am. The Surveyor asked, If a resident is refusing care and becomes combative what should have been done? She stated, Just to stop, and let the patient come down. The Surveyor asked, Were you the charge nurse when this incident happened? She stated, Yes ma'am. The Surveyor asked, When you first observed the incident is there a reason you didn't stop it?' She stated, She wasn't hurting her or anything. She was trying to prevent her from hurting herself. The Surveyor asked, As soon as she became combative should the attempt to provide nail care have stopped? She stated, Yes ma'am. The Surveyor asked, What interventions did the facility put in place to keep this incident from happening again when [Resident #1] receives nail care? She stated, To my knowledge I know [CNA #1] had a suspension, and we talked to everybody about the right to refuse? The Surveyor asked, Did you document the in-service on the right to refuse? She stated, I didn't do one? The Surveyor asked if staff continued to hold down a combative resident and provide nail care what could have happened. She stated, It could have caused serious injury to resident and staff. The resident could have been hurt because she's so frail. j. On 9/02/22 at 12:15 PM, the Surveyor asked the Administrator, Was [Resident #1's] care plan revised as needed, and interventions put in place to prevent this incident from happening again? She stated, She had behaviors already in her care plan, not about nail care. The Surveyor asked, Should interventions have been but in place to keep this incident from happening again. She stated, I talked to [CNA #1] and explained about her being suspended. The Surveyor asked, What in-services did you complete with [CNA #1] when she returned to work? She stated, I spoke to her verbally on abuse and neglect. The Surveyor asked if a staff puts their leg over a resident's leg to prevent movement is it considered a restraint. She stated, Yes anything to prevent movement. k. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation and Reporting, provided by the Administrator Assistant on 9/01/22 at 12:55 PM documented, .Care Plan. Resident/Elders care Plans will address interventions designed to prevent occurrences .Documentation. Nursing staff shall document the incident and interventions in the resident/elder's medical record .

Based on interview and record review the facility failed to ensure an allegation of abuse was reported to the Office of Long Term Care (OLTC) in a timely manner for 1 (Resident) of 3 (Residents #1, #2, #3) sampled residents. The findings are: 1. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/08/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required limited one-person physical assistance with personal hygiene and was independent with walking and transfers. a. The Care Plan with a revision date of 6/14/22 documented, .Resident #1] has a behavior at times such as refusing care .explain all procedures to [Resident #1] before starting . b. The Incident Report dated 7/11/22 documented, .At approximately 3:00 PM 7/11/22 the ADON [Assistant Director of Nursing] was notified by [CNA (Certified Nursing Assistant) #2] that she felt a concern with the way staff were cutting [Resident #1's] fingernails. [CNA #2] stated she was on the porch when she heard someone yelling and when she looked through the window [she] saw [CNA #1] cutting residents nails . Date and time reported to OLTC [Office of Long Term Care]: 7/14/22 . c. The Witness Statement completed by CNA #1 dated 7/11/22 at 3:04 PM documented, .Elder [has] been up all day wandering in and out of room braking [breaking] the blinds to windows. I went in elders' room, and she was trying to brake some more blinds. I asked her what she was doing and had a shoe grabing [grabbing] to blinds bending them. Tryed [tried] to stop her she grabbed my arm with long nails and started twisting and scratching. I pulled my arm back she got mad and walked off. I cleaned and put a band-aid on my hand then I went to get some nail clippers and waited until she was in the living room got her to sit down told her I was going to clip her nails. She was fine until she noticed I was cutting them short enough not to scratch anybody including herself. Then was upset and yelling, scratching, kicking, and trying to bite. Nurse told her she can't bite she said, Yes I can. So, nurse and other worker was trying to distract her and talk to her. I had my leg on top of hers while sitting next to her. I have been kneed in face by elder. Before she was yelling and trying to bite . Other staff member was outside come in and told us the other staff members and nurse that that was abuse. I told her her nails were sharp and very long and needed to be cut . d. On 9/01/22 at 12:52 PM, the Surveyor asked the Administrator, When you are made aware of an allegation of abuse when should it be reported to Office of Long Term Care? She stated, By 11:00 AM the following day. The Surveyor asked, Can you tell me why an allegation of abuse wasn't reported to OLTC until 7/14/22? She stated, The staff talked to the ADON, and she was asked to do a witness statement. The Surveyor asked, What is considered a restraint? She stated, Anything holding a part of the body down, seat belt, chemical. The Surveyor asked, Should staff hold a resident down if they are refusing to get their nails clipped? She stated, No ma'am. The Surveyor asked, What residents did you interview to see if they had been abused? She stated, Nobody had a BIMS high enough to be interviewed. The Surveyor asked, What interventions did you put in place to prevent this incident from happening again? She stated, Sent [CNA #1] home, and skin assessments on everybody in the building. e. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation and Reporting, provided by the Administrator Assistant on 9/01/22 at 12:55 PM documented, Reporting Reasonable Suspicion of a Crime .Abuse or Serious Bodily Injury-2 hour limit: If the events that cause the reasonable suspicion include allegations of abuse or serious bodily injury to a resident, the staff person shall report the suspicion immediately, but not later than two hours after forming the suspicion . Facility staff shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility .

Based on observation, record review, and interview, the facility failed to ensure the care planned level of supervision was provided to a resident with a history of burning himself while smoking and staff responsible for the resident's care were aware of the need to provide supervision and secure cigarette lighters to prevent further potential injury for 1 (Resident #47); and failed to ensure smoking safety assessments were conducted and documented upon admission and at least quarterly to determine the level of supervision necessary to ensure resident safety for 2 (Residents #47 and #20) of 3 (Residents #47, #20 and #34) sampled residents who resided in the [NAME] Cottage and smoked. The facility also failed to ensure cigarette lighters were kept in a secure location and regular monitoring was conducted to ensure compliance with the residents' care planned needs and the facility's smoking policy to prevent potential fire or further potential burn injuries for residents who resided in 1 ([NAME] Cottage) of 6 cottages. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #47, and had the potential to cause more than minimal harm to all 12 residents who resided in the [NAME] Cottage, as documented on the Census by Cottage list provided by the Administrator on 1/3/22 at 9:50 a.m. The Administrator was notified of the immediate jeopardy situation on 1/3/22 at 3:43 p.m. The findings are: 1. Resident #47 had diagnoses of [MEDICATION(S)] Dependence, Other Tobacco Product, Depressive Episodes, Paranoid [CONDITION(S)], and [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/2/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required setup and supervision with locomotion on and off the unit, was independent with transferring, used a wheelchair for mobility, had an active diagnosis of Non-Alzheimer's Dementia, and had no open [CONDITION(S)] or second or third-degree [CONDITION(S)] in the past 7 days. a. The Smoking Safety Screening dated 8/30/21 documented, .Can resident light own cigarette? Yes . Resident need for adaptive equipment: Smoking apron . Does resident need nursing facility to store lighter and cigarettes? Yes . Plan of care is used to assure resident is safe while smoking? Yes . IDTC [Interdisciplinary Team Conference] decision: .Elder dropped cigarette on right thigh and has ongoing treatment to area. Elder will now smoke with apron and supervision as needed. Will re-evaluate at later date. Team decision: Safe to smoke with supervision . b. The Care Plan dated as revised 8/30/21 documented, [Resident #47] chooses to smoke, had dx [diagnosis] of [MEDICATION(S)] dependence . 3/20/19 staff to keep and store lighter up per facility policy . 8/30/2021 [Resident #47] voiced that he dropped his cigarette on his leg . 8/30/2021 When notified of smoking assessment update to wear smoking apron and supervision, he refused . There was no documentation on the Care Plan to indicate any alternate interventions were discussed or developed after the resident refused the smoking apron. c. The Shahbaz Care Plan updated 8/30/21 documented, .Special needs: .Smoker - staff to keep / store lighter per facility policy. d. A Nursing MDS Progress Note dated 8/31/21 documented, This nurse was notified to conduct another smoking assessment 8/30/21, elder stated to staff that he dropped a cigarette on his leg. Smoking assessment was updated to wearing a smoking apron and supervision. When elder was notified he became upset and states, 'Y'all can't make me wear that, I'm not going to and there is no one here that can make me'. This nurse notified DON [Director of Nursing] and Admin [Administrator]. e. On 12/13/21 at 11:19 a.m., the resident was sitting in his wheelchair on the front porch of the cottage, smoking a cigarette, with no smoking apron on. Various nursing staff went in and out the front door, but no staff member was providing continuous supervision to the resident while he smoked. The resident did not drop the cigarette or ashes on himself during the surveyor's observation. f. On 12/14/21 at 8:48 a.m., Certified Nursing Assistant (CNA) #1 was asked, In the [NAME] Cottage, who gets [Resident #47] his cigarettes and lighter when he wants to smoke, and who takes him out? CNA #1 stated Oh, he keeps them in his room, and he takes himself out whenever he wants to go smoke. g. On 12/14/21 at 12:51 p.m., the resident was in his room and was asked, Who takes you to smoke, and do you wear an apron when you are smoking? He stated, I take myself to smoke and no, I don't wear that apron. They wanted me to, but I am not going to. There were 2 packs of cigarettes and a lighter on the bedside table at the end of the bed. There were also 2 old lighters on a shelf in the room. The cigarettes and lighters were within reach of any resident who came into the resident's room. A list provided by Director of Nursing (DON) #1 on 12/16/21 at 1:00 p.m. documented there were 6 residents who resided in the [NAME] Cottage who, have cognitive impairments but can still get around. h. On 12/15/21 at 10:56 a.m., Licensed Practical Nurse (LPN) #1 was asked, Can residents keep their cigarettes and lighters in their rooms? She replied, I don't think they can have their lighter in their rooms; they have to get those from the staff when they want to smoke. i. On 12/16/21 at 3:00 p.m., Director of Nursing (DON) #1 was asked, If [Resident #47] wants to smoke, who does he get his cigarettes and lighter from? She stated, The staff keeps them in a drawer in the kitchen, or in the nurse's desk and sometimes in the med [medication] cart. The DON was asked, Can any of the residents keep their cigarettes and/or lighter in their rooms? The DON stated, No. The DON was asked, Is there a concern regarding safety and accidents if residents are allowed to keep their lighter and cigarettes in their room? She stated, Yes, well they could smoke in their room, and if there is oxygen in use that could be dangerous, and if the other residents get ahold of it that is a true concern. j. On 1/3/22 at 9:45 a.m., surveyors re-entered the facility to further investigate failed practices related to supervision of residents who smoked. DON #1 was no longer available for interview. DON #2 had been employed in the DON position for less than 2 weeks. k. On 1/03/22 at 11:09 a.m., LPN #4 and CNA #1 were asked, Where are the residents' cigarettes and lighters stored? LPN #4 stated, The residents keep their cigarettes in the medication cart and showed the surveyor packs of cigarettes for Resident #20 and another resident who resided in the [NAME] Cottage. The LPN stated she did not have any cigarettes for Resident #47 and, I assume he keeps his own cigarettes. She was asked where he kept them and stated she was not sure if he kept them, in his room or put up. She stated Resident #20, .gets a pack of cigarettes a day and they [residents] smoke whenever they want to . The lighters are kept in the drawer in the kitchen area, generally, and they have to ask for them. CNA #1 stated, The nurse keeps them in the med cart or in the extra medication closet, usually. The LPN and CNA were asked, How do you know what safety precautions are to be used with residents? LPN #4 stated, Oh, I am not sure who assesses that and where to find that information out at this time. CNA #1 stated, The nurses do the assessment on that. They were asked, Is there a smoking schedule for the residents? LPN #4 stated, There is no smoking schedule; they smoke whenever they want to. CNA #1 stated, There is no schedule. They were asked, Who is responsible for supervising the residents when they smoke, if they need it? LPN #4 stated, The aides. CNA #1 stated, Aides. They were asked, How does the facility determine who is safe to smoke alone or with supervision? LPN #4 stated, I am not sure. CNA #1 stated, Social Services Director or the Nurse that is over the cottage does the assessment on the residents. l. On 1/3/22 at 11:33 a.m., DON #2 indicated she was not aware that Resident #47 had cigarettes and lighters in his room on 12/14/21. She was asked to provide a copy of a current smoking assessment for Resident #47 and documentation of what the facility was doing to mitigate the risk of injury to Resident #47 or other residents, related to the resident smoking unsupervised and having lighters found in his room. At 12:30 p.m., the DON provided the smoking assessment dated [DATE] as the most recent smoking assessment for this resident. The DON also provided a typed document that listed the measures to protect residents from potential fire / burn injuries related to smoking residents. It documented, Several safety precautions are in place to ensure that all elders are safe in the event another elder may choose to refuse help or assistance for safety purposes. Red safety smoke cans are placed on each back porch. Lighters are stored by staff so that use can be monitored. Wool fire protection blankets are stored in each library. All residents that chose to not smoke are separated from the designated smoking section by an airlock or two closed doors. All elders are housed in private rooms. The document did not indicate any monitoring was conducted to ensure lighters were secured and residents were supervised in accordance with their assessed and care planned needs. No staff in-servicing or monitoring had been initiated since the original survey exit date of 12/17/21. On 1/3/22 at 5:45 p.m. during the exit conference, the Administrator stated the facility had not initiated any in-services or monitoring prior to 1/3/22 because they were waiting for the 2567 to arrive. m. On 1/3/22 at 11:54 a.m., Resident #47 propelled himself to the back porch to smoke. CNA #1 stated, [Resident #47] won't wear an apron. He's supposed to, but he won't. The resident removed a pack of cigarettes and a lighter from his coat pocket and lit his cigarette. The CNA supervised the smoke break. n. On 1/3/22 at 12:12 p.m., Resident #47 was asked, Where do you keep your cigarettes and lighter when you aren't smoking? He stated, I keep my cigarettes on me, but they keep my lighter at the desk. He was asked, Has anyone ever talked to you about wearing an apron? He stated, Yes, they did, but I'm not going to. He was asked, Have you ever been burned? He stated, Yes, and that's my business. If you want to put me out of here, go ahead. o. On 1/03/22 at 12:20 p.m., CNA #1 was asked where the lighters were kept in the kitchen and stated, They are kept here in this drawer. The CNA opened a drawer and showed the surveyor lighters in Ziplock bags labeled with residents' names. 2. Resident #20 had diagnoses of Hypertension, Diabetes Mellitus Type 2, and Alcohol Dependence with Alcohol-Induced Mood Disorder. The Admission MDS with an ARD of 3/30/21 documented current tobacco use. The Quarterly MDS with an ARD of 9/30/21 documented the resident scored 15 on a BIMS, was independent with transfer, required supervision and set-up help with walking and locomotion. a. The Shahbaz Care Plan updated 7/6/21 documented, .Special needs: .Smoker - staff to store and keep lighter per facility policy . b. The Care Plan dated 10/4/21 documented, [Resident #20] is a smoker, staff to store and keep lighter per facility policy . 10/20/2021 [Resident #20] becomes upset at times with staff about lighter policy, he states, 'I am a grown man, and I don't need no one telling me that I can't keep my cigarettes and lighter'. [Resident #20] is able to smoke without staff supervision . As of 1/3/22, there was no Smoking Safety Screening available for review in the resident's clinical record. c. On 1/3/22 at 10:51 a.m., Resident #20 was on the back porch of the [NAME] Cottage smoking with no staff present. He was asked, Do you smoke on a schedule or do you smoke whenever you want to? He stated, Whenever I want to. He was asked, Do the staff keep your cigarettes and lighter or do you keep them? He stated, I keep them. The nurses are so busy, I hate to interrupt them from what they are doing, so I keep them myself. The resident did not exhibit any unsafe smoking practices during the surveyor's observation. d. On 1/3/22 at 11:33 a.m., DON #2 was asked for a current smoking assessment for Resident #20. e. On 1/3/22 at 11:54 a.m., Resident #20 propelled himself to the back porch to smoke. CNA #1 assisted him with applying a smoking apron, then the resident used a lighter from his pocket to light his cigarette. The CNA remained on the porch to supervise this smoke break. f. On 1/3/22 at 12:30 p.m., DON #2 provided a smoking assessment for Resident #20 with an effective date of 9/24/21 which documented the resident was able to smoke without staff supervision; however, the lock date on the assessment was 1/3/22 and the assessment was signed by LPN #5 on 1/3/22. DON #2 was asked, Does the lock date [of 1/3/22] mean it was completed today? She stated, I don't know. I would have to find out. She was asked, How often are the smoking assessments completed? She stated, I'm not sure. I will have to check. 3. A Smoking Policy provided by DON #1 on 12/15/21 at 2:15 p.m. documented, It is the policy of this facility to ensure a safe environment for all residents who wish to smoke outside at the facility . Any resident that wishes to smoke while a resident at this facility will be required to keep their lighters, matches, electronic cigarettes, as well as other smoking related items, locked up . All residents that wish to smoke will have a smoking assessment completed upon admission and change in condition to determine safety equipment that is needed . Residents will be allowed to smoke at designated times determine by facility and smoking residents' preferences . The first instance where a resident is caught not following the smoking policy will result in a care plan meeting with resident and responsible party to ensure resident and responsible party understand the policy . Second instance where a resident is caught not following the smoking policy may result in the resident receiving an immediate discharge notice due to safety in facility being jeopardized . On 1/3/22 at 5:45 p.m. during the exit conference, the Administrator stated this policy provided by DON #1 on 12/15/21 was not the facility's policy but did not provide a different smoking policy for the facility at this time. Per the regulation at 483.90(i)(5) - tag F926, facilities are required to establish policies regarding smoking, smoking areas, and smoking safety. 4. The immediate jeopardy was removed, and the scope/severity reduced to E on 1/3/22 at 5:30 p.m. when the facility implemented the following plan of removal: 1/3/2022 Plan of Removal. Department heads made rounds in each cottage all rooms for cigarette and lighters are to be secured by staff - [Activities Director] & [and] [Social Services Director] for residents at all times. Inservice taken around and staff signed. Rounds were conducted 1/3/22. If it is care planned for a resident to wear a smoking apron while smoking, they are to be supervised to ensure that all cigarettes and lighters are being kept by staff. Reviewing Care Plans and interventions to be done by [LPN #5] MDS and [LPN #1] MDS. Every shift should check resident's rooms to ensure that all cigarettes and lighter are being kept by staff. Inservice conducted by [Activities] and [Social Services]. If at any time you observed a resident that appears to need to be given a smoking assessment, please notify your DON and Administrator immediately. All smoking assessments to be done today on all smoking elders - MDS [LPN #5] and [LPN #1] MDS. All these inservices will be done this shift and all shifts x [times] 1 week. Then we will monitor 3 times a week for 8 weeks by all department heads.

Complaint # (AR 251) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure correct use and maintenance of side rails, as evidenced by failure to ensure side rail assessments accurately identified entrapment risk; failure to attempt to use appropriate alternatives prior to initiating the use of side rails; failure to ensure signed, informed consents outlining the potential risks versus benefits of side rail use were completed; and failure to ensure side rails were routinely monitored and inspected to ensure proper functioning to prevent entrapment and / or potential injury for 2 (Residents #1 and #2) of 4 (Residents #1, #2, #3 and #5) case mix residents who used side rails. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused serious harm, injury or death for Resident #1, who was found hanging upside-down from the side rail, and Resident #2, who had side rails in use and was found on the floor. The failed practices also had the potential to cause more than minimal harm to 41 residents who used side rails according to a list provided by the Director of Nursing (DON) on 4/3/18 at 4:00 p.m. The facility was informed of the Immediate Jeopardy situation on 4/3/18 at 12:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was totally dependent on 2 plus staff for bed mobility transfers did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period, displayed continuous inattention and disorganized thinking, had a feeding tube, and did not use side rails. a. A Side Rail Evaluation form dated 3/26/18 documented the resident used half side rails due to weakness and being non ambulatory. It documented side rails would assist the resident by providing a sense of security and keep the resident from rolling out of bed. It documented entrapment was not a risk factor, that side rails were recommended, and that the side rails would not be considered a restraint. b. The Care Plan dated 3/26/18 documented in the Problem section, (Resident #1) has limited physical mobility related to Alzheimer's. (Resident #1) is bed bound and non-verbal. She is totally dependent on staff for care. There was no documentation in the Care Plan to address the potential risks involved with using side rails. c. A Nurse's Note dated 3/29/18 at 5:09 a.m. documented, This nurse was summoned to Elder's room due to (feeding) pump beeping. This nurse observed Elder lying on left side with pillows to her back, HOB (head of bed) at 45 degree angle. She was noted to have moderate amount of emesis on floor beside bed with clear liquid, small amount of formula and small amount of blood. Scant amount of blood from left nostril. Pump was turned off. Also a small amount of blood noted at G (gastrostomy) Tube site. B/P (blood pressure) 145/69, Pulse 91 . d. A Nurse's Note dated 3/29/18 at 5:46 p.m. documented, Nurse called to resident's room by CNA (Certified Nursing Assistant). Resident has redness noted to left cheek that appears to be swollen and resident has signs of pain. Tylenol 325 two tabs (tablet) given per [DEVICE] at 1415 (2:15 p.m.). Physician notified and gave order at 1416 (2:16 p.m.) to send resident to ER (emergency room ) for eval (evaluation) . e. The hospital Emergency Department (ED) Physician Record dated 3/29/18 documented, Final diagnosis / Clinical Impression: Petechiae. Vomiting. UTI (urinary tract infection). f. The Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 3/29/18 documented, (Licensed Practical Nurse (LPN) #5) called Director of Nursing at 2:02 p.m. regarding a change of condition in elder (Resident #1). LPN reported to Director of Nursing that elder had swelling and discoloration to left cheek bone and left orbital region of face. (CNA #1) was called in for questioning by Director of Nursing. At 3:00 p.m., (CNA #1) informed the Director of Nursing of event occurring on 3/28/18 between the hours of 1:30 a.m. and 2:00 a.m. (CNA #1) stated to Director of Nursing 'between 1:30 - 2:00 a.m., me and the night shift nurse did rounds on her because her pump was still going off. We found (Resident #1) hanging off bed from mid waist.' Half side rails were up on bed. Per side rail evaluation assessment done on 3/26/18, entrapment not an issue with this incident. g. On 4/3/18 at 5:05 a.m., the resident was in bed positioned toward her right side with the head of the bed elevated to approximately 45 degrees. There were bilateral half side rails in the up position and padded with sheep skin. The bed was in the lowest position. The resident was on an Ultra Care Excel Low Air Loss Alternating Mattress and had a pillow between her and the side rail to her left. A wedge positioning device was against the resident's back and pillows were between the resident's knees. There was also a wedge under the resident's lower extremities. The head of the resident's bed was in the raised position, and when the surveyor used her hands to apply weight to the mattress, at the point where it was bent to allow head elevation, a large gap was created between the mattress and the side rail. h. On 4/3/18 at 5:51 a.m., CNA #1 demonstrated how she and LPN #1 found the resident on the morning of 3/29/18. She positioned herself on her left side and draped her torso around the half side rail, with her head and upper body, including her arms, dangling toward the floor. The side rail was holding her in place in the rib cage area. The CNA stated, My normal cottage is #1. They asked me to work in #2 that night. I got over there and made my rounds. She (resident) was fine. She was positioned on her left side and both side rails were up. The bed was in the low position, but not quite all the way as far as it could go. I did a round on her around 12:30 a.m., because her feeding pump was beeping. She was dry, so she didn't need changing. And she was snoring. I called the nurse about her feeding pump. She (nurse) was in cottage #3 because of something that was going on over there. She came over here, and we went into the room between 1:30 a.m. and 2:00 a.m. and found her (resident) like that. She had kind of thrown up. Her face wasn't touching the floor, but there was like, some bloody mucus vomit on the floor beneath her face. We laid her on her back and saw blood in her nose and around her PEG (percutaneous endoscopic gastrostomy) tube on her gown. She doesn't talk, so I have no idea how or why she was bleeding. The nurse told me to get her vital signs and she was going to get a hold of the head nurse. Her O2 (oxygen) sat (saturation) was 85, but we didn't have an O2 concentrator. I came over here to this cottage, and they didn't have an extra. She (nurse) got a tank out of the closet but, couldn't get the regulator off of it. I checked the resident's O2 sat again, and it had come up to 96. The CNA was asked if the resident was wedged between the mattress and side rail. She stated, No, she wasn't wedged. She was just draped around it and hanging off the bed. The left side of her face was red, like blood had went to her face. Like it had pooled. And what I don't understand, this part of the side rail (the end of the rail toward the foot of the bed) was on the floor. She was asked what she meant by that. She stated, I mean, you can pivot this rail up toward the head of the bed, but this one was the opposite direction with this (bottom of rail) touching the floor. She was asked if the rail was supposed to do that and stated, I don't know. I know that when I walked in her room, my heart dropped. It mortified me. I'm here to help these people, not let something like that happen. She was asked if she had been in-serviced since the incident. She stated, We've had abuse / neglect and a few more since that happened. She was asked why the resident had side rails. She stated, I don't really know. i. On 4/3/18 at 6:47 a.m., LPN #2, who routinely provided care to Resident #1 on night shift, was asked why the resident needed side rails. She stated, To me, it's to protect her from falling off the bed. It's for her safety, and she's had those side rails for as long as I have been here. j. On 4/3/18 at 9:45 a.m., LPN #3 was asked if she was responsible for doing the side rail assessments on the residents. She stated, I do the assessments for the long term care residents. She was asked why Resident #1 was assessed as needing side rails. She stated, To the best of my knowledge, the reason I chose that answer, is because she's totally dependent on staff. She's had a side rail for as long as I have known her. She was asked how she determined there was no entrapment risk when she went in to assess the resident for side rails. She stated, I've been educated more since then. We are all learning. She was asked if the residents or their representatives had signed informed consents for the side rails. She stated, We got an email several days ago about revamping our side rail evals and we're in the process now of getting consents for the side rails. She was asked if she knew of any type of monitoring system for the side rails. She stated, I don't know. That's part of our revamp. k. On 4/3/18 at 10:28 a.m., the Maintenance Supervisor was asked if he had a routine inspection schedule to check side rails for proper functioning. He stated, The day after the incident, they sent me around to check all of them for looseness and stuff. He was asked if there was anything wrong with Resident #1's side rail and stated, I put a new spring in her side rail. l. On 4/3/18 at 1:40 p.m., CNA #2, who routinely provided care to Resident #1 on the day shift, was asked about the resident's bed mobility. She stated, I've never seen her move anything but her arms. When I did rounds on her that day (3/29/18), I could see that her cheek was red, but later on, I saw her cheek looking like it was swollen. I got the nurse. She was asked why the resident had side rails. She stated, I don't see her really having no (any) use for them, because she doesn't use them to pull herself up or anything. m. On 4/4/18 at 10:51 a.m., the DON was asked to explain the incident involving Resident #1. She stated, The LPN sent me a text at 3:49 a.m. that notified me the resident had been found with vomit on the floor and blood in her nostril and around her [DEVICE]. I didn't wake up 'til 5 something, because I didn't hear the beep . She (LPN) didn't tell me anything about how the resident was positioned when she was found. She made it sound like she just hung her head over and vomited. The day shift LPN noted swelling to her face, so we sent her out. I got a hold of the CNA and wrote down everything she was saying and then I called the Administrator. The information she (CNA #1) gave me, compared to what the nurse told me . I was floored. All of the side rails were assessed by maintenance. Staff was in-serviced on abuse and neglect, and we did a reportable. We finally got in touch with the LPN and, when the Administrator was telling her she was suspended pending the outcome of the investigation, she resigned. The DON was asked if there was any kind of routine schedule where someone checked the side rails for proper functioning. She stated, There is now. But before the incident, if we identified a problem with anything, he would come running. She was asked why the care plan didn't reflect that the resident used side rails. She stated, Side rails have been added to the CNA care plans. The CNAs don't have access to the comprehensive care plans, but we are going to add side rails to the comprehensive care plans today. She was asked why Resident #1 had side rails. She stated, At one time, she would assist with holding herself over. But, I think we were lacking in the assessments and reassessments of the side rails. The DON was asked how long the resident had been using side rails. She stated, I don't know. I'm not sure there's any way to find that out. The DON was asked if all the residents were reassessed for appropriate use of side rails after the incident and she stated, We rounded on each room and did audits on all the residents to see who had what kind of side rail. As of 4/4/18, no reassessment had been conducted for the continued use of side rails for Resident #1. n. On 4/4/18 at 11:59 a.m., the Administrator was asked about the incident involving Resident #1. She stated, My first thought was . (Resident #1) doesn't move. But I talked to her daughter-in-law (DIL), and she (DIL) said when she (resident) gets sick, she does lean over to throw up. She was asked if the facility had a routine maintenance schedule for the side rails to ensure proper functioning. She stated, We have our quarterly assessments, but as far as a maintenance schedule, no. She was asked if the resident had a Physician order [REDACTED]. She stated, No. She was asked if there were informed consents for the residents who used side rails. She stated, We have consents for the residents who could sign them, but we have mailed the others out. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/5/18 documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required extensive assistance from 2 or more staff for bed mobility, exhibited continuous inattention and disorganized thinking and did not use side rails. a. A Side Rail Evaluation dated 2/15/18 documented the resident needed side rails due to weakness, balance deficit, fear of falling out of bed, non-ambulatory and that side rails would assist the resident with turning side to side in bed, moving up and down in bed, improving balance in bed, supporting self in transfer, providing sense of security, avoid rolling out of bed. It documented that entrapment was not a risk factor, that side rails were recommended and that the side rails would not be considered a restraint. b. An Incident Report dated 3/19/18 at 10:25 p.m. documented, Aides called to my attention that (Resident #2) had slid out of his bed onto the floor, unwitnessed, with the draw sheet and sheet underneath him. I asked (Resident #2) did he hit or bump his head. He stated that he didn't bump or hit his head. I checked (Resident #2) for any signs of bruising, swelling or redness from his head to his toes. None noted. He has no complaint of pain or discomfort. Neuro (neurological) checks in progress and within normal limits. He stated that the bed was very uncomfortable . The report documented, Predisposing Physiological Factors: Confused . Gait imbalance . Impaired memory . Weakness. c. The Care Plan dated 3/22/18 documented in the Problem section, (Resident #2) has an ADL (activities of daily living) self-care performance deficit related to Dementia, Disease process: [MEDICAL CONDITION], impaired balance. There was no documentation in the Care Plan to address the potential risks involved with using side rails. d. On 4/3/18 at 5:35 a.m., the resident was in bed and there were bilateral side rails in the raised position. The resident was lying on his back and had slid over to where his right shoulder was pressing against the side rail and his feet were pointing toward the opposite corner of the mattress toward the foot of the bed. CNA #3 stated, He doesn't like his new mattress. He never used to get like this in the bed, until he got this mattress from Hospice. e. On 4/3/18 at 5:47 a.m., CNA #1 was asked why Resident #2 used side rails. She stated, His wife got that mattress for him, and it was delivered by Hospice. All I know is that he used to be able to get up. I don't know why he has the side rails. When he had the other mattress, he did fine. He didn't move around. f. On 4/4/18 at 10:51 a.m., the DON was asked if alternatives were used prior to installing side rails for the resident. She stated, I know I told them to try a low bed after his fall. I didn't know he was using side rails. 3. The Immediate Jeopardy was removed, and the scope and severity lowered to E, on 4/4/18 at 11:24 a.m. when the facility implemented the following Plan of Removal: a. Side rail assessments will be completed on 4/3/18 on all residents by (LPN #3, RN (Registered Nurse) #1 and LPN #4) with side rails to verify accuracy of need for side rails. Any resident beds with side rails will be rendered inoperable if not assessed for side rails. b. On 4/3/18 side rails will be removed on Resident #1's bed. c. Starting on 4/3/18, staff will be in-serviced by Assistant DON, DON, and (LPN #4) on side rail use as they report to work until all clinical staff members are in-serviced. d. Starting 4/3/18, the DON/Designee will review all new admissions for side rail assessment and accuracy weekly. e. Starting 4/3/18, a weekly monitoring tool will be started by DON/ADON (Assistant DON) to assess elders that have side rails. f. Contacted equipment company on 4/3/18 to come to facility to evaluate all bed equipment including side rails, mattresses, and frame. Hospice company coming to evaluate the same equipment. g. On 4/3/18, the MDS Consultant evaluated department head nursing on side rail assessment with return demonstration after identifying prior assessments. Then completed all new side rail assessments on elders using side rails. h. Effective immediately, 4/4/18 and on an ongoing basis, any elder with side rails in use, who is observed attempting to climb or roll out of bed, as well as any elder who falls or becomes entrapped, will be immediately reassessed by the DON/Designee to determine if side rails should be removed and/or if an alternative intervention would be more appropriate. i. DON/Designee will review all I&As (Incidents and Accidents) weekly to determine if side rails were involved and if reassessment of side rails is needed.

Complaint # (AR 251) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent accidents, by failing to ensure side rail assessments accurately identified entrapment risk and failing to ensure routine inspections of side rails were conducted to ensure proper functioning, to prevent entrapment and / or potential injury for 2 (Residents #1 and #2) of 4 (Residents #1, #2, #3 and #5) case mix residents who used side rails. The facility failed to identify side rails as a potential hazard for these residents; failed to reassess / evaluate Resident #1 for a safer alternative after the resident was found suspended from the side rail; and failed to reassess / evaluate Resident #2 for a safer alternative after he fell or climbed out of bed with side rails in use and was found on the floor. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused serious harm, injury or death for Resident #1, who was found hanging upside-down from the side rail, and Resident #2, who had side rails in use and was found on the floor. The failed practices also had the potential to cause more than minimal harm to 41 residents who used side rails, according to a list provided by the Director of Nursing (DON) on 4/3/18 at 4:00 p.m. The facility was informed of the Immediate Jeopardy situation on 4/3/18 at 12:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was totally dependent on 2 plus staff for bed mobility, transfers did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period, displayed continuous inattention and disorganized thinking, had a feeding tube, and did not use side rails. a. A Side Rail Evaluation form dated 3/26/18 documented the resident used half side rails due to weakness and being non ambulatory. It documented side rails would assist the resident by providing a sense of security and keep the resident from rolling out of bed. It documented entrapment was not a risk factor, that side rails were recommended, and that the side rails would not be considered a restraint. b. The Care Plan dated 3/26/18 documented in the Problem section, (Resident #1) has limited physical mobility related to Alzheimer's. (Resident #1) is bed bound and non-verbal. She is totally dependent on staff for care. There was no documentation in the Care Plan to address the potential risks involved with using side rails. c. A Nurse's Note dated 3/29/18 at 5:09 a.m. documented, This nurse was summoned to Elder's room due to (feeding) pump beeping. This nurse observed Elder lying on left side with pillows to her back, HOB (head of bed) at 45 degree angle. She was noted to have moderate amount of emesis on floor beside bed with clear liquid, small amount of formula and small amount of blood. Scant amount of blood from left nostril. Pump was turned off. Also a small amount of blood noted at G (gastrostomy) Tube site. B/P (blood pressure) 145/69, Pulse 91 . d. A Nurse's Note dated 3/29/18 at 5:46 p.m. documented, Nurse called to resident's room by CNA (Certified Nursing Assistant). Resident has redness noted to left cheek that appears to be swollen and resident has signs of pain. Tylenol 325 two tabs (tablet) given per [DEVICE] at 1415 (2:15 p.m.). Physician notified and gave order at 1416 (2:16 p.m.) to send resident to ER (emergency room ) for eval (evaluation) . e. The hospital Emergency Department (ED) Physician Record dated 3/29/18 documented, Final diagnosis / Clinical Impression: Petechiae. Vomiting. UTI (urinary tract infection). f. The Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 3/29/18 documented, (Licensed Practical Nurse (LPN) #5) called Director of Nursing at 2:02 p.m. regarding a change of condition in elder (Resident #1). LPN reported to Director of Nursing that elder had swelling and discoloration to left cheek bone and left orbital region of face. (CNA #1) was called in for questioning by Director of Nursing. At 3:00 p.m., (CNA #1) informed the Director of Nursing of event occurring on 3/28/18 between the hours of 1:30 a.m. and 2:00 a.m. (CNA #1) stated to Director of Nursing 'between 1:30 - 2:00 a.m., me and the night shift nurse did rounds on her because her pump was still going off. We found (Resident #1) hanging off bed from mid waist.' Half side rails were up on bed. Per side rail evaluation assessment done on 3/26/18, entrapment not an issue with this incident. g. On 4/3/18 at 5:05 a.m., the resident was in bed positioned toward her right side with the head of the bed elevated to approximately 45 degrees. There were bilateral half side rails in the up position and padded with sheep skin. The bed was in the lowest position. The resident was on an Ultra Care Excel Low Air Loss Alternating Mattress and had a pillow between her and the side rail to her left. A wedge positioning device was against the resident's back and pillows were between the resident's knees. There was also a wedge under the resident's lower extremities. The head of the resident's bed was in the raised position, and when the surveyor used her hands to apply weight to the mattress, at the point where it was bent to allow head elevation, a large gap was created between the mattress and the side rail. h. On 4/3/18 at 5:51 a.m., CNA #1 demonstrated how she and LPN #1 found the resident on the morning of 3/29/18. She positioned herself on her left side and draped her torso around the half side rail, with her head and upper body, including her arms, dangling toward the floor. The side rail was holding her in place in the rib cage area. The CNA stated, My normal cottage is #1. They asked me to work in #2 that night. I got over there and made my rounds. She (resident) was fine. She was positioned on her left side and both side rails were up. The bed was in the low position, but not quite all the way as far as it could go. I did a round on her around 12:30 a.m., because her feeding pump was beeping. She was dry, so she didn't need changing. And she was snoring. I called the nurse about her feeding pump. She (nurse) was in cottage #3 because of something that was going on over there. She came over here, and we went into the room between 1:30 a.m. and 2:00 a.m. and found her (resident) like that. She had kind of thrown up. Her face wasn't touching the floor, but there was like, some bloody mucus vomit on the floor beneath her face. We laid her on her back and saw blood in her nose and around her PEG (percutaneous endoscopic gastrostomy) tube on her gown. She doesn't talk, so I have no idea how or why she was bleeding. The nurse told me to get her vital signs and she was going to get a hold of the head nurse. Her O2 (oxygen) sat (saturation) was 85, but we didn't have an O2 concentrator. I came over here to this cottage, and they didn't have an extra. She (nurse) got a tank out of the closet but, couldn't get the regulator off of it. I checked the resident's O2 sat again, and it had come up to 96. The CNA was asked if the resident was wedged between the mattress and side rail. She stated, No, she wasn't wedged. She was just draped around it and hanging off the bed. The left side of her face was red, like blood had went to her face. Like it had pooled. And what I don't understand, this part of the side rail (the end of the rail toward the foot of the bed) was on the floor. She was asked what she meant by that. She stated, I mean, you can pivot this rail up toward the head of the bed, but this one was the opposite direction with this (bottom of rail) touching the floor. She was asked if the rail was supposed to do that and stated, I don't know. I know that when I walked in her room, my heart dropped. It mortified me. I'm here to help these people, not let something like that happen. She was asked if she had been in-serviced since the incident. She stated, We've had abuse / neglect and a few more since that happened. She was asked why the resident had side rails. She stated, I don't really know. i. On 4/3/18 at 6:47 a.m., LPN #2, who routinely provided care to Resident #1 on night shift, was asked why the resident needed side rails. She stated, To me, it's to protect her from falling off the bed. It's for her safety, and she's had those side rails for as long as I have been here. j. On 4/3/18 at 9:45 a.m., LPN #3 was asked if she was responsible for doing the side rail assessments on the residents. She stated, I do the assessments for the long term care residents. She was asked why Resident #1 was assessed as needing side rails. She stated, To the best of my knowledge, the reason I chose that answer, is because she's totally dependent on staff. She's had a side rail for as long as I have known her. She was asked how she determined there was no entrapment risk when she went in to assess the resident for side rails. She stated, I've been educated more since then. We are all learning. She was asked if she knew of any type of monitoring system for the side rails. She stated, I don't know. That's part of our revamp. k. On 4/3/18 at 10:28 a.m., the Maintenance Supervisor was asked if he had a routine inspection schedule to check side rails for proper functioning. He stated, The day after the incident, they sent me around to check all of them for looseness and stuff. He was asked if there was anything wrong with Resident #1's side rail and stated, I put a new spring in her side rail. l. On 4/3/18 at 1:40 p.m., CNA #2, who routinely provided care to Resident #1 on the day shift, was asked about the resident's bed mobility. She stated, I've never seen her move anything but her arms. When I did rounds on her that day (3/29/18), I could see that her cheek was red, but later on, I saw her cheek looking like it was swollen. I got the nurse. She was asked why the resident had side rails. She stated, I don't see her really having no (any) use for them, because she doesn't use them to pull herself up or anything. m. On 4/4/18 at 10:51 a.m., the DON was asked to explain the incident involving Resident #1. She stated, The LPN sent me a text at 3:49 a.m. that notified me the resident had been found with vomit on the floor and blood in her nostril and around her [DEVICE]. I didn't wake up 'til 5 something, because I didn't hear the beep . She (LPN) didn't tell me anything about how the resident was positioned when she was found. She made it sound like she just hung her head over and vomited. The day shift LPN noted swelling to her face, so we sent her out. I got a hold of the CNA and wrote down everything she was saying and then I called the Administrator. The information she (CNA #1) gave me, compared to what the nurse told me . I was floored. All of the side rails were assessed by maintenance. Staff was in-serviced on abuse and neglect, and we did a reportable. We finally got in touch with the LPN and, when the Administrator was telling her she was suspended pending the outcome of the investigation, she resigned. The DON was asked if there was any kind of routine schedule where someone checked the side rails for proper functioning. She stated, There is now. But before the incident, if we identified a problem with anything, he would come running. She was asked why the care plan didn't reflect that the resident used side rails. She stated, Side rails have been added to the CNA care plans. The CNAs don't have access to the comprehensive care plans, but we are going to add side rails to the comprehensive care plans today. She was asked why Resident #1 had side rails. She stated, At one time, she would assist with holding herself over. But, I think we were lacking in the assessments and reassessments of the side rails. The DON was asked how long the resident had been using side rails. She stated, I don't know. I'm not sure there's any way to find that out. The DON was asked if all the residents were reassessed for appropriate use of side rails after the incident and she stated, We rounded on each room and did audits on all the residents to see who had what kind of side rail. As of 4/4/18, no reassessment had been conducted for the continued use of side rails for Resident #1. n. On 4/4/18 at 11:59 a.m., the Administrator was asked about the incident involving Resident #1. She stated, My first thought was . (Resident #1) doesn't move. But I talked to her daughter-in-law (DIL), and she (DIL) said when she (resident) gets sick, she does lean over to throw up. She was asked if the facility had a routine maintenance schedule for the side rails to ensure proper functioning. She stated, We have our quarterly assessments, but as far as a maintenance schedule, no. She was asked if the resident had a Physician order [REDACTED]. She stated, No. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/5/18 documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required extensive assistance from 2 or more staff for bed mobility, exhibited continuous inattention and disorganized thinking and did not use side rails. a. A Side Rail Evaluation dated 2/15/18 documented the resident needed side rails due to weakness, balance deficit, fear of falling out of bed, non-ambulatory and that side rails would assist the resident with turning side to side in bed, moving up and down in bed, improving balance in bed, supporting self in transfer, providing sense of security, avoid rolling out of bed. It documented that entrapment was not a risk factor, that side rails were recommended and that the side rails would not be considered a restraint. b. An Incident Report dated 3/19/18 at 10:25 p.m. documented, Aides called to my attention that (Resident #2) had slid out of his bed onto the floor, unwitnessed, with the draw sheet and sheet underneath him. I asked (Resident #2) did he hit or bump his head. He stated that he didn't bump or hit his head. I checked (Resident #2) for any signs of bruising, swelling or redness from his head to his toes. None noted. He has no complaint of pain or discomfort. Neuro (neurological) checks in progress and within normal limits. He stated that the bed was very uncomfortable . The report documented, Predisposing Physiological Factors: Confused . Gait imbalance . Impaired memory . Weakness. c. The Care Plan dated 3/22/18 documented in the Problem section, (Resident #2) has an ADL (activities of daily living) self-care performance deficit related to Dementia, Disease process: [MEDICAL CONDITION], impaired balance. There was no documentation in the Care Plan to address the potential risks involved with using side rails. d. On 4/3/18 at 5:35 a.m., the resident was in bed and there were bilateral side rails in the raised position. The resident was lying on his back and had slid over to where his right shoulder was pressing against the side rail and his feet were pointing toward the opposite corner of the mattress toward the foot of the bed. CNA #3 stated, He doesn't like his new mattress. He never used to get like this in the bed, until he got this mattress from Hospice. e. On 4/3/18 at 5:47 a.m., CNA #1 was asked why Resident #2 used side rails. She stated, His wife got that mattress for him, and it was delivered by Hospice. All I know is that he used to be able to get up. I don't know why he has the side rails. When he had the other mattress, he did fine. He didn't move around. f. On 4/4/18 at 10:51 a.m., the DON was asked if alternatives were used prior to installing side rails for the resident. She stated, I know I told them to try a low bed after his fall. I didn't know he was using side rails. 3. The Immediate Jeopardy was removed, and the scope and severity lowered to E, on 4/4/18 at 11:24 a.m., when the facility implemented the following Plan of Removal: a. Side rail assessments will be completed on 4/3/18 on all residents by (LPN #3, RN (Registered Nurse) #1 and LPN #4) with side rails to verify accuracy of need for side rails. Any resident beds with side rails will be rendered inoperable if not assessed for side rails. b. On 4/3/18 side rails will be removed on Resident #1's bed. c. Starting on 4/3/18, staff will be in-serviced by Assistant DON, DON, and (LPN #4) on side rail use as they report to work until all clinical staff members are in-serviced. d. Starting 4/3/18, the DON/Designee will review all new admissions for side rail assessment and accuracy weekly. e. Starting 4/3/18, a weekly monitoring tool will be started by DON/ADON (Assistant DON) to assess elders that have side rails. f. Contacted equipment company on 4/3/18 to come to facility to evaluate all bed equipment including side rails, mattresses, and frame. Hospice company coming to evaluate the same equipment. g. On 4/3/18, the MDS Consultant evaluated department head nursing on side rail assessment with return demonstration after identifying prior assessments. Then completed all new side rail assessments on elders using side rails. h. Effective immediately, 4/4/18 and on an ongoing basis, any elder with side rails in use, who is observed attempting to climb or roll out of bed, as well as any elder who falls or becomes entrapped, will be immediately reassessed by the DON/Designee to determine if side rails should be removed and/or if an alternative intervention would be more appropriate. i. DON/Designee will review all I&As (Incidents and Accidents) weekly to determine if side rails were involved and if reassessment of side rails is needed.

Complaint # (all or in part) was substantiated in these findings Based on record review and interview the facility Administration failed to develop and implement an effective system of monitoring the quality of care and quality of life of the residents in order to ensure Residents #1, #4, #13, #14 and #15 were free from abuse as evidenced by the facility's failures to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin and staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. The Administrator Designee Job description was obtained from the facility on 11/8/13 and it documented the "Guide" job description as: The guide coaches, directs, and monitors the quality of care and the quality of life of the elders in The Green House Homes. The guide acts as a direct supervisor to the self-managed work team of Shahbazism and is responsible for evaluating the outcomes of their work. The Role of the guide and other administrative personnel in The Green House home remains that of oversight and directions, just as in a traditional nursing home, The title "Guide" is assigned to the Administrator or their designee to denote the style of leadership and direction that is now expected by them. The role of the Guide is to oversee compliance, competence and operational issues and to provide monitoring and assistance to individual Shahbazim and to the team, directly or through the team coordinators. 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 3. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing

Complaint # (all or in part) was substantiated in these findings Based on record review and interview the facility failed to ensure thier abuse policy and procedure was followed as evidenced by the facilities failures to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. The Abuse and Neglect policy and procedures for investigation and reporting obtained from the ADON on 11/6/13 at 3:19 p.m., documented, "...All incidents of alleged resident mistreatment, neglect, or abuse including injuries of unknown cause and misappropriation of resident property MUST BE REPORTED IMMEDIATELY TO THE FACILITY COMPLIANCE OFFICER AND ADMINISTRATOR.... An intrenal investigation will be initiated immediately in every case of alleged resident neglect, abuse, mistreatment... and/or resident injury from unknown cause... The identification of the investigating process will include interviews with appropriate personsm including: Facility employees, The resident, the resident's roommate, other residents, family members, visitors in the facility, any other persons who may have knowledge of the incident... The facility will encourage residents, families, and employees to report incidents and will not tolerate any acts of retribution of reporting...." 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 3. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and bein

Based on record review and interview, the facility failed to ensure Residents #1, #4, #13, #14 and #15 were free from abuse. The facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. The failed practices had the potential to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 2. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all staff currently on duty to be re-inserviced by the nurse consultant and other staff to be re-inserviced by the DON as they report to work on policy regarding to who they should report alleged abuse or neglect, that being the Charge Nurse on duty and including who and how to report if staff is afraid of retaliation: This will be the Cottage Team Guide or Facility Administrator. e. On 11/7/13 at 3:20 p.m., Guides will be inserviced on how to complete one-on-one interviews with staff and cognitive residents that include detailed descriptions from anyone who should have knowledge of any event related to allegations of abuse of neglect. f. Rules of reporting will be posted in the laundry room of each cottage as well as at the time clock. g. All staff determined to withhold information or failure to report will be suspended pending investigation and disciplinary action up to and including termination. h. On 11/7/13 at 3:15 p.m., Guides/designee for each cotta

Complaint # (all or in part) was substantiated in these findings Based on record review and interview, the facility failed to ensure Residents #1, #4, #13, #14 and #15 were free from abuse. The facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. The failed practices had the potential to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 2. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all staff currently on duty to be re-inserviced by the nurse consultant and other staff to be re-inserviced by the DON as they report to work on policy regarding to who they should report alleged abuse or neglect, that being the Charge Nurse on duty and including who and how to report if staff is afraid of retaliation: This will be the Cottage Team Guide or Facility Administrator. e. On 11/7/13 at 3:20 p.m., Guides will be inserviced on how to complete one-on-one interviews with staff and cognitive residents that include detailed descriptions from anyone who should have knowledge of any event related to allegations of abuse of neglect. f. Rules of reporting will be posted in the laundry room of each cottage as well as at the time clock. g. All staff determined to withhold information or failure to report will be suspended pending investigation and disciplinary action up to and including

Complaint # (all or in part) was substantiated in these findings Based on record review and interview, the facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 2. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all staff currently on duty to be re-inserviced by the nurse consultant and other staff to be re-inserviced by the DON as they report to work on policy regarding to who they should report alleged abuse or neglect, that being the Charge Nurse on duty and including who and how to report if staff is afraid of retaliation: This will be the Cottage Team Guide or Facility Administrator. e. On 11/7/13 at 3:20 p.m., Guides will be inserviced on how to complete one-on-one interviews with staff and cognitive residents that include detailed descriptions from anyone who should have knowledge of any event related to allegations of abuse of neglect. f. Rules of reporting will be posted in the laundry room of each cottage as well as at the time clock. g. All staff determined to withhold information or failure to report will be suspended pending investigation and disciplinary action up to and including termination. h. On 11/7/13 at 3:15 p.m., Guides/designee for each cottage will int

Based on record review and interview the facility failed to ensure thier abuse policy and procedure was followed as evidenced by the facilities failures to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. The Abuse and Neglect policy and procedures for investigation and reporting obtained from the ADON on 11/6/13 at 3:19 p.m., documented, "...All incidents of alleged resident mistreatment, neglect, or abuse including injuries of unknown cause and misappropriation of resident property MUST BE REPORTED IMMEDIATELY TO THE FACILITY COMPLIANCE OFFICER AND ADMINISTRATOR.... An intrenal investigation will be initiated immediately in every case of alleged resident neglect, abuse, mistreatment... and/or resident injury from unknown cause... The identification of the investigating process will include interviews with appropriate personsm including: Facility employees, The resident, the resident's roommate, other residents, family members, visitors in the facility, any other persons who may have knowledge of the incident... The facility will encourage residents, families, and employees to report incidents and will not tolerate any acts of retribution of reporting...." 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 3. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all sta

Based on record review and interview, the facility failed to ensure Residents #1, #4, #13, #14 and #15 were free from abuse. The facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. The failed practices had the potential to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m. b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor. c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person. Section III - Findings and Action Taken documented, On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, (Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in. 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, .Van driver reported to me that x-ray had been done. Rt (right) tibia was broken. Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'. 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over. 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, (Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse. d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated That mean girl pushed me into the stool. CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, That mean girl pushed me into the stool. CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told We came back and started getting witness statements. She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, Tell me what happened from the time you came on duty until Resident #1 was sent out. She stated, I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today? CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up. CNA #6 was then asked, Why does your witness statement state that you went to get her up and that she was on the side of the bed? She stated, (CNA #5) grabbed me by my arm and told me what to write in the witness statement. She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked What do you think would have happened if you had told them the truth on 10/9/13? She replied They would have investigated it different. At 1:10 p.m., CNA #6 was asked, Did they give you a form or did they interview you? CNA #6 stated, The charge nurse asks us about it and (CNA #5) answered all the questions. She was then asked, If someone had pulled you aside would you have told them the truth? She replied, Yes, Ma'am, I would have. g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place. On 11/7/13 at 10:20 a.m., CNA #8 was asked, What do you remember the day (Resident #1's) leg was broken? She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, Was the resident in a wheelchair? She replied, No, we drug her with a dining room chair to the table. The CNA stated, The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower. The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, They gave me a witness form and told me to write what I knew about (Resident #1's) leg. CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, They dropped me in the shower and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 2. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you. CNA #7 stated she overheard CNA #5 tell Resident #15 to lay down and shut up. CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for Resident is at nutrition risk. 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food. There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified. On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, Who would you report an allegation too? The Dietary Manager stated, The DON, I would not have reported anything to the old Administrator. 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head. A witness statement form signed by CNA #7 and dated 11/3/13 documented, Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, Ok, Ok, Ok, I won't do it again, I'm sorry. On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, Ouch,Ouch. She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, Why did you not report this? She stated, I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser. 4) A form dated 11/5/13 and completed by the Social Director documented, Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who? The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, Not, hit, but get aggressive with them and she stated it was (CNA #5). b. Resident #13 had [DIAGNOSES REDACTED]. The Annual MDS with and ARD of 10/10/13 documented the resident scored a 15 (13-15 indicates cognitively intact) on the BIMS, required extensive assistance for bed mobility, transfer, toileting and personal hygiene and required limited assist of one for locomotion. 1) The Plan of Care developed 10/10/13 documented a problem of Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm. with interventions Support Elders strengths and coping skills. Discuss with elder ways to utilize present coping skills to deal with situations that arise. 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'. A witness statement dated 11/2/13 and signed by CNA #7 documented, Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light. A witness statement dated 11/2/13 and signed by CNA #6 documented, Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will. 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, Why did you not report this? The CNA stated, I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser. 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, How did it make you feel when (CNA #5) told you not to use your call light? She stated, It made me mad as hell. She really didn't like me. I feel better now that she is gone. c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of Resident is at nutrition risk. Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like. with an intervention of staff to feed elder. 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food. A Witness statement form dated 11/2/13 and signed by CNA #7 documented, Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat. A Witness statement form dated 11/2/13 signed by CNA #6 documented, Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat. 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, I told her that you can't make her do that. At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of History of being very demanding and impatient with staff and intolerant of others at times with interventions that included Teach elder on positive behaviors. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and 'Lay down unless she is going to change herself'. A witness form dated 11/2/13 and signed by CNA #6 documented, The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor. A witness form dated 11/2/13 and signed by CNA #7 documented, Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'. 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to Shut up and Lay down unless you want to change yourself. She stated that she told CNA #5 You can't tell them to shut up and lay down and I will report you if you do it again. CNA #7 was asked, Why did you not report this? She stated I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I know that me not reporting is bad but I have to work and I didn't know who report to. I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser. 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 Just did everything wrong. 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter. 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.' On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, So she was allowed to work the next day? The DON stated, Yes. The Administrator Designee was asked. Did you report this? She stated No. She was then asked, Why not? She replied, I don't know, we should have. 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an H when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all staff currently on duty to be re-inserviced by the nurse consultant and other staff to be re-inserviced by the DON as they report to work on policy regarding to who they should report alleged abuse or neglect, that being the Charge Nurse on duty and including who and how to report if staff is afraid of retaliation: This will be the Cottage Team Guide or Facility Administrator. e. On 11/7/13 at 3:20 p.m., Guides will be inserviced on how to complete one-on-one interviews with staff and cognitive residents that include detailed descriptions from anyone who should have knowledge of any event related to allegations of abuse of neglect. f. Rules of reporting will be posted in the laundry room of each cottage as well as at the time clock. g. All staff determined to withhold information or failure to report will be suspe

Complaint # , substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure an allegation of emotional abuse was immediately reported to the Administrator and failed to thoroughly investigate the allegation of emotional abuse for 1 of 1 case mix resident (Resident #17) who was the alleged victim of emotional abuse. This failed practice had the potential to affect 3 residents who had nutritional risks and resided in Cottage 6, according to the Roster Matrix provided by the Administrator on 9/9/13. The findings are: Resident #17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/13 documented the resident scored a 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), had a poor appetite and trouble concentrating and required extensive assistance with eating. a. The Division of Medical Services form 762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long term Care Facilities, documented, "...Date Incident Reported to OLTC (Office of Long Term Care): 8/21/13 at 11:00 a.m., Date and Time of Incident (if known): 8/15/13 at 12:00 p.m., Date and Time of Discovery: 8/20/13 at 10:30 a.m... Emotional/Mental Abuse... Section II-Complete Description of Incident... It was reported by a Shabazz (specially trained direct care staff) that she witnessed another Shabazz talking to the Elder (Resident) and saying if she did not sit down and eat she (Shabazz) will call the police and they will put her outside." The Resident Plan of Care documented a problem dated 6/30/13 of, "Resident is at nutrition risk: related to: Failure to thrive. Disease process/condition (list); Dementia. Her appetite is fair. She would rather drink fluids than eat. She received supplements as ordered." There was no documentation on the care plan of an approach that involved threatening the resident to encourage her to eat. b. A OLTC Witness Statement Form documented, "August 20, 2013 (Shabazz (Certified Nursing Assistant (CNA) #10)) On August 15, 2013... while assisting her to the table, I told her to be quiet, sit down and eat her food." c. Additional OLTC Witness Statement Forms documented as follows: "8/20/13 (Elder) Yes, I've heard them say they was going to call the police. That's the only way they can get her to eat..." "8/21/13 (Shabazz (CNA #11))... Her daughter said to tell her whatever to get her to eat even if its saying call the police..." "8/21/13 (Licensed Practical Nurse (LPN #3)) ...have heard her daughter tell staff to tell her to eat cause (daughter's name) said so or to say (name) said so or (name) said so, with the last being police men here in (name of town)." "8/21/13 (Shabazz (CNA #12)) ...she (daughter) herself suggested that the ladies call her or (name). (Resident #17) then say's 'I'll eat honey don't call the police.' I just found out that (name) was a sheriff a long time ago and that's how she (daughter) got her mother to eat..." "8/21/13 (Shabazz (CNA #13)) ...Her daughter (name) say to her we are going to call (name) I never knew who he was until they say he's a police..." d. On 9/12/13 at 3:10 p.m., the Director of Nursing (DON) was asked, "Do you know where the witness statement is from the Shabazz who made the allegation?" She stated, "I'm not sure. I can ask (Administrator)." The names from the witness statements were read off to her and she stated, "No, it wasn't any of them. She was only here for a few days, I think." She was asked about the delay in reporting. She stated, "I don't really know. It may have been a weekend. I'm not sure how long she was here. She only worked a couple of days. I'm not over the Shabazz (CNA's)." e. On 9/12/13 at 3:40 p.m., the Administrator was asked for the witness statements from the Shabazz (CNA) who reported the allegation. She stated, "Everything should be in there." She reviewed the file and stated, "I'll look in my file." She stated, "I had to call her on the phone and ask her about it, because there was a rumor going on about this." She was asked what she meant by a rumor. She stated, "I heard that this Shabazz (CNA) was upset about this and so I called her." She was asked, "How did you hear about it?" She stated, "From another Shabazz. She told me about it so I called the other Shabazz." She stated "They were doing it because the daughter told them to do whatever it took." As of 9/13/13 at 2:00 p.m., no further Witness Statements were provided, including those from the two Shabazz that reported to the Administrator on 8/20/13.

Based on record review and interview, the facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin. The facility failed to ensure staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 2. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports to work. d. On 11/7/13 at 3:15 p.m., all staff currently on duty to be re-inserviced by the nurse consultant and other staff to be re-inserviced by the DON as they report to work on policy regarding to who they should report alleged abuse or neglect, that being the Charge Nurse on duty and including who and how to report if staff is afraid of retaliation: This will be the Cottage Team Guide or Facility Administrator. e. On 11/7/13 at 3:20 p.m., Guides will be inserviced on how to complete one-on-one interviews with staff and cognitive residents that include detailed descriptions from anyone who should have knowledge of any event related to allegations of abuse of neglect. f. Rules of reporting will be posted in the laundry room of each cottage as well as at the time clock. g. All staff determined to withhold information or failure to report will be suspended pending investigation and disciplinary action up to and including termination. h. On 11/7/13 at 3:15 p.m., Guides/designee for each cottage will interview and document cognitive residents and staff daily to determine any

Complaint , substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure their abuse policy and procedures were followed, by failing to ensure an allegation of emotional abuse was immediately reported to the Administrator and failure to ensure the allegation of emotional abuse was thoroughly investigated for 1 of 1 case mix resident (Resident # 17) who was the alleged victim of emotional abuse. This failed practice had the potential to affect 12 residents who had nutritional risks and resided in Cottage 6, according to the Roster Matrix provided by the Administrator on 9/9/13. The findings are: 1. The facility's Abuse and Neglect Policy and Procedure, provided by the Administrator on 9/9/13, documented, "...3. Investigation/Reporting. All incidents of alleged resident mistreatment, neglect, or abuse...MUST BE REPORTED IMMEDIATELY TO THE FACILITY COMPLIANCE OFFICER AND ADMINISTRATOR... The investigation should determine whether an incident has occurred, to what extent the resident was mistreated, by whom, and the measures needed to protect residents from further incidents... Any employee who fails to report actual or suspected abuse, neglect, or misappropriation of property immediately upon discovery will be subject to disciplinary action up to and including termination... 4. Protecting residents from further incidents; and preventing further occurrences during investigation...The facility will undertake other Protective and Preventive measures as follows: In an effort to protect a resident who had allegedly been abused,... the suspected employee(s) will be suspended immediately from employment until an investigation has been determined that the employee is no longer a suspect... 7. Protecting Resident, Family Member, and/or staff from retaliation for reporting mistreatment. This facility does not tolerate any form of resident mistreatment. It requires all employees to report suspicions and allegations of mistreatment as soon as they become known, and all residents, family members and staff may make reports without fear of retaliation from the facility..." 2. Resident #17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/13 documented the resident scored a 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), had a poor appetite and trouble concentrating and required extensive assistance with eating. a. The Division of Medical Services form 762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long term Care Facilities, documented, "...Date Incident Reported to OLTC (Office of Long Term Care): 8/21/13 at 11:00 a.m., Date and Time of Incident (if known): 8/15/13 at 12:00 p.m., Date and Time of Discovery: 8/20/13 at 10:30 a.m... Emotional/Mental Abuse... Section II-Complete Description of Incident... It was reported by a Shabazz (specially trained direct care staff) that she witnessed another Shabazz talking to the Elder (Resident) and saying if she did not sit down and eat she (Shabazz) will call the police and they will put her outside." The Resident Plan of Care documented a problem dated 6/30/13 of, "Resident is at nutrition risk: related to: Failure to thrive. Disease process/condition (list); Dementia. Her appetite is fair. She would rather drink fluids than eat. She received supplements as ordered." There was no documentation on the care plan of an approach that involved threatening the resident to encourage her to eat. b. A OLTC Witness Statement Form documented, "August 20, 2013 (Shabazz (Certified Nursing Assistant (CNA) #10)) On August 15, 2013... while assisting her to the table, I told her to be quiet, sit down and eat her food." c. Additional OLTC Witness Statement Forms documented as follows: "8/20/13 (Elder) Yes, I've heard them say they was going to call the police. That's the only way they can get her to eat..." "8/21/13 (Shabazz (CNA #11))... Her daughter said to tell her whatever to get her to eat even if its saying call the police..." "8/21/13 (Licensed Practical Nurse (LPN #3)) ...have heard her daughter tell staff to tell her to eat cause (daughter's name) said so or to say (name) said so or (name) said so, with the last being police men here in (name of town)." "8/21/13 (Shabazz (CNA #12)) ...she (daughter) herself suggested that the ladies call her or (name). (Resident #17) then say's 'I'll eat honey don't call the police.' I just found out that (name) was a sheriff a long time ago and that's how she (daughter) got her mother to eat..." "8/21/13 (Shabazz (CNA #13)) ...Her daughter (name) say to her we are going to call (name) I never knew who he was until they say he's a police..." d. On 9/12/13 at 3:10 p.m., the Director of Nursing (DON) was asked, "Do you know where the witness statement is from the Shabazz who made the allegation?" She stated, "I'm not sure. I can ask (Administrator)." The names from the witness statements were read off to her and she stated, "No, it wasn't any of them. She was only here for a few days, I think." She was asked about the delay in reporting. She stated, "I don't really know. It may have been a weekend. I'm not sure how long she was here. She only worked a couple of days. I'm not over the Shabazz (CNA's)." e. On 9/12/13 at 3:40 p.m., the Administrator was asked for the witness statements from the Shabazz (CNA) who reported the allegation. She stated, "Everything should be in there." She reviewed the file and stated, "I'll look in my file." She stated, "I had to call her on the phone and ask her about it, because there was a rumor going on about this." She was asked what she meant by a rumor. She stated, "I heard that this Shabazz (CNA) was upset about this and so I called her." She was asked, "How did you hear about it?" She stated, "From another Shabazz. She told me about it so I called the other Shabazz." She stated "They were doing it because the daughter told them to do whatever it took." As of 9/13/13 at 2:00 p.m., no further Witness Statements were provided, including those from the two Shabazz that reported to the Administrator on 8/20/13.

Based on record review and interview the facility Administration failed to develop and implement an effective system of monitoring the quality of care and quality of life of the residents in order to ensure Residents #1, #4, #13, #14 and #15 were free from abuse as evidenced by the facility's failures to ensure injuries of unknown origin were thoroughly investigated for 1 of 1 (Resident #1) case mix resident who had a fracture of unknown origin and staff immediately reported any witnessed incident of staff to resident abuse to the Administrator or Designee to ensure prompt protection for the residents. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 5 of 5 (Resident #s 1, 4, 13, 14 and 15) case mix residents who were the alleged victims of allegations of staff to resident abuse. The facility was notified of the Immediate Jeopardy on 11/7/13 at 2:34 p.m. This failed practice had the potential to cause more than minimal harm to all 71 residents according to the Resident Census and Conditions of Residents form dated 10/28/13. The finding are: 1. The Administrator Designee Job description was obtained from the facility on 11/8/13 and it documented the "Guide" job description as: The guide coaches, directs, and monitors the quality of care and the quality of life of the elders in The Green House Homes. The guide acts as a direct supervisor to the self-managed work team of Shahbazism and is responsible for evaluating the outcomes of their work. The Role of the guide and other administrative personnel in The Green House home remains that of oversight and directions, just as in a traditional nursing home, The title "Guide" is assigned to the Administrator or their designee to denote the style of leadership and direction that is now expected by them. The role of the Guide is to oversee compliance, competence and operational issues and to provide monitoring and assistance to individual Shahbazim and to the team, directly or through the team coordinators. 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/13 documented the resident usually was understood and usually understands, scored a 6 (0-6 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent for bed mobility, transfers, toilet use and personal hygiene, used a wheelchair for mobility and had limited range of motion on one lower extremity. a. Nurses notes dated 10/9/13 at 7:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Shahbaz (Certified Nursing Assistant) notified this nurse that elder (Resident #1) c/o (complained of) leg px (pain). Assessed Elder's legs. Found area below rt. (right) knee the size of a grapefruit. Area is tender to touch, no heat noted. Notified Dr. (doctor). Appt (appointment) being set up in office this a.m..." b. Nurses notes dated 10/9/13 at 8:00 a.m. and signed by LPN #1 documented, "Called Dr. (name) to give update that elder was on her way to office. Respon (responsible) party '(name)' notified that Elder has COC (change of condition) and is on her way to Dr. (name) office. DON (Director of Nurses), ADON (Assistant Director of Nurses) notified. 9:42 a.m. Shahbaz notified nurse that x-ray complete. Elders Rt Tibia is broken. Elder is being transferred via (by way of) facility van to (local hospital) notified (responsible party), DON and ADON. 1400 (2:00 p.m.) Elder returned to facility via family auto. Awake, Alert with confusion. New orders are as follows: Repeat Rt. knee x-ray in two weeks, et (and) six weeks. Send report to Dr. (name). Knee immobilizer to rt. knee. Elevate rt. leg while in bed. 100% assist. Fall precautions. [MEDICATION NAME] 5/500 mg (milligrams) 1/2 to 1 tab PO (by mouth) q (every) 6 hrs (hours.) Watch for (increased) pain, swelling, sob (shortness of breath), weakness et notify Dr. (name). Mobilizer is in place. Elder c/o px (pain) at 2:50 p.m. gave [MEDICATION NAME] 5/500 mg one tab per orders. Elder transferred to bed. Knee/leg supported and elevated. Family here @ (at) bedside. Will continue to monitor." c. A DMS 762, Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, documented the date/time of discovery as 10/9/13 at 7:05 a.m. The resident involved was Resident #1. The findings and actions taken documented, "The elder is alert and oriented to person only. Elder requires extensive assistance X (times) 1 person with ADL'S (activities of daily living) and total assistance with mobility via wheelchair. Elder has the following Diagnosis: [REDACTED]. Elder was admitted on [DATE] due to [MEDICAL CONDITION]. Elder has severe cognitive impairment and is unable to remember to use call light due to Dementia. Elder often repeats questions asked of her. Elder is reoriented to time and place frequently. Staff makes frequent checks on her while she is in her room. Elder is able to understand at times and is able to verbalize her responses. Elders has a BIMS score of 6 on last MDS. Elder is unable to do daily tasks without extensive assistance x 1 person." Section III - Findings and Action Taken documented, "On October 9, 2013, Shahbaz (Certified Nursing Assistant) brought to the attention of the charge nurse that Elder was unable to stand due to pain in the right leg and swelling below, right knee. Shahbaz went into (Resident #1's) room at 7:05 a.m., to get her up for the day and found (Resident #1) was sitting up on the edge of bed. Shahbaz attempted to assist Elder to stand. Elder unable to stand and was complaining of pain. Elder was assisted X 2 people to wheelchair and was taken to table for breakfast. Elder was at dining table eating breakfast when charge nurse assessed her right leg. Nurse found a knot the size of grapefruit below right knee that was discolored and tender to the touch. no heat noted to the area. Elder was able to move right leg. Facility Charge nurse immediately notified (Hospital emergency room ). Spoke with (emergency room nurse) and was told to transport Elder via facility van to (physician) office due to elder being able to sit in wheelchair. Facility Charge nurse notified (physician) office that Elder was in route to office and gave full report of incident. X-rays were taken at (physician) office and facility van driver reported to Facility Charge Nurse of a broken right tibia and that Elder was being transported by facility van to (Hospital in another city). Elder told (physician) that she had fell in the shower on the Friday before the incident. Elder had not voiced any falls or complaints of pain or discomfort before this am. Elder returned to facility from (hospital) on the same day via facility van. [DIAGNOSES REDACTED]. Right leg placed in an immobilizer at (hospital). Upon notification of the incident, an investigation was started immediately. 11-7 Shahbaz was immediately put on suspension until investigation complete. All staff, CNA's and Nurses, were interviewed and all staff is unaware of any incident that happened. Skin audits were done on (Resident #1) on October 10 and 11, 2013, no bruising to any other part of her body that would be consistent with a fall were found. Skin audits were done cottage wide with no negative findings on other Elders. I spoke with (Resident #1's) family and they told me that the ER doctor at (hospital) had informed them that (Resident #1) has very thin bones. Upon conclusion of the investigation, it is determined that the Elder is very frail and has [MEDICAL CONDITION] that has caused brittle bones. There was no identified mechanism of injury. My assessment is that Elder may have had a minor event that went unnoticed along with the [DIAGNOSES REDACTED]. The family, physician and the police department were notified of the incident. The Shahbaz was allowed to return to work in cottage 6 after investigation was complete. The staff was inserviced about Abuse and Neglect. The facility will continue to monitor changes in ALL elders and care plan appropriate changes concerning the best course of treatment for [REDACTED]. 1) A witness statement signed by CNA #9 dated 10/10/13 documented, "(Resident #1) did not complain of any pain 10/8/13. I checked on her every two hours and she actually was sleeping. I went in at 5 (a.m.) that morning (10/9/13) and let her know she wasn't getting up this time because it was her bath day and that day shift will get her up. I changed her and left out the room. I left early that morning at 6:00 after that CNA #5 and CNA #8 came in." 2) A witness statement signed by LPN #1 and dated 10/9/13 documented, "...Van driver reported to me that x-ray had been done. Rt (right) tibia was broken... Van driver also informed me that Elder said she had fallen in the shower. I ask my 7-3 (7 a.m. - 3 p.m.) Shahbaz did she (resident) get a shower. They stated, 'No shower given this morning'..." 3) A witness statement signed by CNA #5 dated 10/9/13 at 7:30 a.m. documented, "CNA #6 came and got me from another patient's room and said (Resident #1) can't walk. I looked at her right knee because that's the leg she was complaining about. It was swollen and a little blue. We called nurse real quick right then the nurse came over from cottage #1 she then came right over." 4) A witness statement signed by CNA #6 dated 10/9/13 at 7:30 a.m. documented, "(Resident #1) was sitting on side of bed when I walked in her room. I tried to get her to stand up she said she couldn't walk her right leg was blue around knee and had a knot on it. I got CNA #5 and we told nurse." d. On 11/6/13 at 3:15 p.m., there was no documentation that the resident was interviewed or that alert/oriented residents were interviewed. The Administrator Designee stated that they did not interview the resident because she was on pain medication. The Interim Administrator stated that the Social Director did not remember interviewing alert/orient residents. e. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that she got a call from CNA #7 on 11/2/13 around 5:00 p.m., and the CNA stated that she needed to talk to her about something but not at the facility and not on the phone. At 5:45 p.m., the DON and ADON met with CNA #7 at approximately 5:45 p.m. at the old nursing home. CNA #7 stated she talked with Resident #1 about her leg and the resident stated "That mean girl pushed me into the stool." CNA #7 stated that she got CNA #6 who asked the resident the same thing and the resident stated, "That mean girl pushed me into the stool." CNA #7 also stated that the injury was at the right place to have been pushed into the stool. CNA #6 told her that she had seen CNA #5 in the bathroom with the resident the morning they sent her out. The ADON then stated that as soon as she was told "We came back and started getting witness statements." She also stated that CNA #6 told them that her witness statement regarding the 9th of October was false. She stated that they gave the witness forms to the staff and had them to fill it out. f. On 11/7/13 at 9:05 a.m., CNA #6 was asked, "Tell me what happened from the time you came on duty until Resident #1 was sent out." She stated, "I came in at round 7:00 a.m., it was my first day in Cottage 6, and so I stood at the front because I didn't know them. I asked (CNA #5) who got showers today?" CNA #5 told me that Resident #4 and Resident #1 did. (CNA #5) took me into (Resident #1's) room and showed me how to walk the resident into the shower. (Resident #1) was standing naked in the shower room when I left to do (Resident #4's) shower. When I came back (Resident #1) walked from her room to the dining room- she was limping- I never heard her say anything about her knee hurting. (CNA #5) said she didn't give her (Resident #1) a shower just washed her up." CNA #6 was then asked, "Why does your witness statement state that you went to get her up and that she was on the side of the bed?" She stated, "(CNA #5) grabbed me by my arm and told me what to write in the witness statement." She stated that on 11/2/13 after the resident stated that a mean girl had pushed her into the stool and the place that was broke matches the level of the toilet that she told the truth to the ADON and DON. She was asked "What do you think would have happened if you had told them the truth on 10/9/13?" She replied "They would have investigated it different." At 1:10 p.m., CNA #6 was asked, "Did they give you a form or did they interview you?" CNA #6 stated, "The charge nurse asks us about it and (CNA #5) answered all the questions." She was then asked, "If someone had pulled you aside would you have told them the truth?" She replied, "Yes, Ma'am, I would have." g. A witness statement signed by CNA #8 on 10/9/13 at 7:30 a.m. documented, "I was working the kitchen, (CNA #5) called me out to look at (Resident #5) leg. It looked as if her knee cap had slipped out of place." On 11/7/13 at 10:20 a.m., CNA #8 was asked, "What do you remember the day (Resident #1's) leg was broken?" She stated that she was working in the kitchen and CNA #5 was with Resident #1 and CNA #6 was with Resident #4. CNA #5 yelled out for CNA #6 to come and CNA #6 went to the Resident's room. They started to walk Resident #1 but she couldn't walk, they got her to the doorway, then (CNA #4) drug a chair from the dining room to the door way and they placed the resident on it and pulled her to the dining room. She further stated that CNA #5 pulled the resident's pant leg up and showed her the resident's leg. CNA #8 was asked, "Was the resident in a wheelchair?" She replied, "No, we drug her with a dining room chair to the table." The CNA stated, "The van driver told me that the resident told the MD (doctor) that the girl let her fall in the shower." The CNA stated the facility had not interviewed her about the incident prior to this day (11/7/13). On 11/7/13 at 1:15 p.m., CNA #8 stated, "They gave me a witness form and told me to write what I knew about (Resident #1's) leg." CNA #8 stated if they had interviewed her, she would have told them the entire story. h. On 11/7/13 at 10:35 a.m., Licensed Practical Nurse (LPN) #1 (charge nurse for cottage 6 on the day Resident #1 was sent to the hospital) was interviewed. She stated that she was in Cottage 1 passing medications when she was notified to come to Cottage 6. She stated that Resident #1 was already at the dining table. She stated that CNA #5 told her the resident was sitting on the side of her bed and complained of leg pain. She stated that she looked at the resident's leg but did not think it was broken. The LPN stated that she talked to CNA #5 and CNA #6 when they were together and that CNA #5 did all the talking. She stated that the resident had a bed alarm on and wondered why the alarm did not sound. She stated that she looked and the alarm had been turned off. She stated the van driver called and told her the resident stated, "They dropped me in the shower" and she reported that to the DON. She stated the family also stated the resident told them that she fell in the shower. She stated that if CNA #6 had told her about it that she would have went to the DON and got CNA #5 out of here. 3. On 11/6/13 at 3:40 p.m., the Assistant Director of Nurse (ADON) stated that during the meeting with CNA #7 on 11/2/13, the CNA stated that she overheard CNA #5 tell Resident #13 "tell me if you need to go to the bathroom, because if you are on your light in 10 minutes, I won't come and take you." CNA #7 stated she overheard CNA #5 tell Resident #15 to "lay down and shut up." CNA #7 stated she saw CNA #5 hit Resident #4 in the head. CNA #7 stated she saw CNA #5 holding Resident #14 down when she feeds her and won't let her have any fluids until she eats her food. a. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 9/30/413 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors and required extensive assistance of one for eating, toilet use and personal hygiene. 1) The Plan of Care documented a problem dated 6/30/13 crossed out with the date 9/30/13 hand written for "Resident is at nutrition risk... 8/23/13 Elder becomes very anxious during meals @ (at) dining table. Elder is constantly talking, excessive asking questions, asking to constantly go to her room. Talks continuously even while food is in her mouth. Requires constant cueing and prompting to eat and chew her food." There was no documentation on the care plan of any interventions related to the 8/23/13 problem. 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date & time of discovery as 10/31/13 at 6:18 p.m. The Summary of the events documented, "At 6:10 p.m., on 10/31/2013, dietary manager was in Cottage 6 at the dining table and was encouraging Elder, (Resident #4) to eat supper when Shahbaz (CNA #5) straightened up the elder's chair and told Elder, 'You gonna be quiet, stop talking, it's rude to talk with your mouth full.' Elder told the dietary manager she wanted to go to her room stating 'I don't want to do anything wrong.' The steps taken documented, "Shahbaz (CNA #5) was immediately suspended after allegation was made. Shahbaz will remain on suspension pending the outcome of the investigation. An investigation has been immediately initiated. Family, law enforcement and doctor have been notified." On 11/7/13 at 12:00 p.m., the Dietary Manager stated that she witnessed the above documented event. That she told the DON and Nurse Consultant and they immediately got CNA #5 off the floor. The Dietary Manager stated that she took the resident to her room and the resident wanted her to stay with her because she didn't want to do anything bad, so she stayed with her until they got her ready for bed. The Dietary Manager was asked, "Who would you report an allegation too?" The Dietary Manager stated, "The DON, I would not have reported anything to the old Administrator." 3) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m., and the person reporting the incident was CNA #7. The summary documented, "During investigation of abuse allegations, it was discovered by investigation staff that on 11/2/13, (CNA #7) reported to ADON and DON that (CNA #5) had hit (Resident #4) in the head for talking too much. This incident happened one morning when (CNA #7) had given (Resident #4) a shower. Resident #4 was at the table complaining of her hair being wet. (CNA #7) went and got a towel and put it on her head. (Resident #4) stated that she needed to go to the bathroom and she wanted to go to bed. (CNA #7) witnessed (CNA #5) lean down and whisper something in (Resident #4's) ear and then she slapped (Resident #4) in the right side of her head." A witness statement form signed by CNA #7 and dated 11/3/13 documented, "Team leader has hit (Resident #4) in the head for talking too much. This incident happened one morning after I gave her a shower. (Resident #4) was at the table complaining of her hair being wet. I went and got a towel and put it on her head. (Resident #4) was saying she needed to go to the bathroom and she wanted to go to bed. Team leader (CNA #5) whispered in (Resident #4's) ears and slapped her in the right side of her head. CLARIFICATION 11/6/13 I told team leader (CNA #5) do not let me see her hit anyone else. She said, "Ok, Ok, Ok, I won't do it again, I'm sorry." On 11/7/13 at 8:45 a.m., CNA #7 stated that about 3 weeks ago she started seeing things that she didn't think was right, around the 21st of October. She stated that she had given Resident #4 a shower and she was complaining because her hair was wet. She went and got a towel and placed it on the resident's head. The resident started yelling that she wanted to go to her room. Then CNA #5 came over, leaned down and whispered something in the resident's ear and then hit her in the head. The resident stated, "Ouch,Ouch." She stated that she told CNA #5 that she would report her if she didn't stop. She stated that this happened about 3 weeks ago. CNA #7 was asked, "Why did you not report this?" She stated, "I didn't know who to report it to; the DON and Administrator didn't work together. The Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable. I was told that I had to report it to Team Leader (CNA #5) first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) A form dated 11/5/13 and completed by the Social Director documented, "Has a staff member ever hit you or have you seen a staff member hit another Elder, if yes. Who?" The alert/oriented residents were identified by the room number and (Resident #15), stated, 'Yes, No, I don't remember the name I can't tell you.' The other 3 residents stated No. (non-case mix resident room number) stated, "Not, hit, but get aggressive with them and she stated it was (CNA #5)." b. Resident #13 had [DIAGNOSES REDACTED]. 1) The Plan of Care developed 10/10/13 documented a problem of "Elder has alternation in mood state as evidence by: Anxiety and depression r/t (related to) not being able to walk and lost function of left arm." with interventions "Support Elders strengths and coping skills... Discuss with elder ways to utilize present coping skills to deal with situations that arise..." 2) A DMS 7734, Incident and Accident Next Day Reporting Form documented the date & time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and #7. The summary of the incident documented, "During an investigation of an abuse allegation, it was discovered by the investigating staff on 11/2/13, (CNA #6) and (CNA #7), both CNAs reported to ADON, DON and Administrator Designee that (CNA #5) team leader of cottage 6 has told (Resident #13) 'you better tell me now if you need to use the bathroom because you better not hit that call light in 10 minutes needing to go because I am not going to come in there and take you to the bathroom'." A witness statement dated 11/2/13 and signed by CNA #7 documented, "Team leader (CNA #5) has told (Resident #13) not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now. CLARIFICATION 11/6/13, I have told team leader she can't tell her not to hit her call light." A witness statement dated 11/2/13 and signed by CNA #6 documented, "Team leader (CNA #5) told (Resident #13) that she needed to tell her right now if she needed to go to bathroom, you better tell her now because you not going to go push the light 10 minutes from now cause she won't come in there. I told (Resident #13) it was ok because I'll take her to bathroom any time she needs me to. CLARIFICATION: 11/6/13 I told team leader she didn't have to take her I will." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 tell Resident #13 that (not to go in her room and hit her call light in 10 minutes because she's not coming in there and if she needs to go to the bathroom to tell her now) when she was pushing her in from outside smoking. CNA #7 was asked, "Why did you not report this?" The CNA stated, "I didn't know who to report it to, the DON and Administrator didn't work together. The Administrator would come down and she and CNA #5 would go out back and smoke for 2 hours at a time and CNA #5 told me that she was here to stay and that everyone else was dispensable... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:20 a.m., Resident #13 was asked, "How did it make you feel when (CNA #5) told you not to use your call light?" She stated, "It made me mad as hell... She really didn't like me... I feel better now that she is gone." c. Resident #14 had a [DIAGNOSES REDACTED]. 1) The Plan of Care developed 3/20/13 and updated 6/20/13 and 9/27/13 documented a problem of "Resident is at nutrition risk... Elder has a good appetite. Staff has to assist with feeding. Elder unable to ask for something to drink or to eat. Elder will push your hand away when she is full or if it's something she doesn't like." with an intervention of "staff to feed elder." 2) A DMS 7734, Incident and Accident next Day Reporting form, documented the date & time of discovery as 11/2/13 at 6:15 p.m., and staff reporting as CNA #6 and #7. The summary documented, "On 11/2/13, (CNA #6 and #7), both CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5) team leader for Cottage 6 had held down the arms of Resident #14 at meal service and forcing her to eat and won't let her drink until she eats her food." A Witness statement form dated 11/2/13 and signed by CNA #7 documented, "Team leader has held (Resident #14's) hands down and force fed her on several different occasions. CLARIFICATION 11/6/13 She would hold her hands down and feed her. After eating she would let her hands go. Did not report because it didn't seem like abuse to hold her hands down because that the only way (CNA #5) could get her to eat." A Witness statement form dated 11/2/13 signed by CNA #6 documented, "Team leader holds down (Resident #14) hand to feed her and also force feeds (Resident #4). Won't let them drink until they eat. CLARIFICATION OF STATEMENT: 11/6/13 She didn't keep her hands down the whole time, she would let go. (Resident #14) swings hand around and scratches you when you don't feed enough. I didn't think was abuse that's the only way (CNA #5) could get her to eat." 3) On 11/7/13 at 8:45 a.m., CNA #6 stated that CNA #5 always held this resident's hands down. She further stated, "I told her that you can't make her do that." At 9:05 a.m., CNA #6 stated that she had never had to hold Resident #14's hand that she eats just fine for her. d. Resident #15 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/6/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was dependent for toilet use/personal hygiene and incontinent of bowel/bladder. 1) The Plan of Care developed 12/4/12 and updated on 3/18/13, 6/6/13 and 9/6/13 documented a problem of "History of being very demanding and impatient with staff and intolerant of others at times" with interventions that included "Teach elder on positive behaviors." 2) A DMS 7734, Incident and Accident Next Day Reporting Form, documented the date and time of discovery as 11/2/13 at 6:15 p.m. and the persons reporting the incident as CNA #6 and CNA #7. The summary documented, "On 11/2/13, (CNA #6 and #7) CNAs came to ADON, DON and Administrator Designee and reported that (CNA #5), team leader of cottage 6 has double briefed elder. (CNA #6) also stated that (CNA #5) takes the call light from her (Resident #15). ( CNA #7) also stated that (CNA #5) has told elder to 'Shut up' and "'Lay down unless she is going to change herself'." A witness form dated 11/2/13 and signed by CNA #6 documented, "The team leader puts two briefs on (Resident #15) all the time. She also takes call light from her. CLARIFICATION: 11/6/13 The reason (CNA #5) one this is because (Resident #15) always peeing no matter how much you wipe her off it's still rolling out. Team leader said we're allowed to do this to keep her from peeing in floor." A witness form dated 11/2/13 and signed by CNA #7 documented, "Team leader has told (Resident #15) to Shut up and when changing her told her to lay down unless she is going to change her diaper herself. (Resident #15) is double briefed when team leader works. CLARIFICATION: 11/6/13 I told team leader not to tell her to shut-up and it's her right to sit up if she wants to. Team leader response was 'Ok,Ok,Ok'." 3) On 11/7/13 at 8:45 a.m., CNA #7 stated that she overheard CNA #5 telling this resident to "Shut up" and "Lay down unless you want to change yourself." She stated that she told CNA #5 "You can't tell them to shut up and lay down and I will report you if you do it again." CNA #7 was asked, "Why did you not report this?" She stated "I didn't know who to report it to, the DON and Administrator didn't work together, the Administrator would come down and she and (CNA #5) would go out back and smoke for 2 hours at a time and (CNA #5) told me that she was here to stay and that everyone else was dispensable... I know that me not reporting is bad but I have to work and I didn't know who report to... I was told that I had to report it to Team Leader first. I didn't know to tell the DON. They never told me what to do if the next person in charge is the abuser." 4) On 11/8/13 at 9:30 a.m., Resident #15 stated that CNA #5 told her to lay down and shut up. She stated that she was afraid of CNA #5 and that CNA #5 had hit her on her back. She stated that CNA#5 "Just did everything wrong." 3. On 11/7/13 at 8:45 a.m., CNA #7 stated that now CNA #5 was gone that the residents are eating more and Resident #4 now comes out of her room. The Elders are not afraid anymore. On 11/7/13 at 9:05 a.m., CNA #6 stated, "I've seen a difference in them (Elders). (Resident #4) is now feeding herself, they are eating better and it's a lot quieter." 4. On 11/7/13 at 12:00 p.m., the Grievance log was reviewed. A grievance form dated 10/30/13 documented, "Care plan meeting held today for (Resident #4). Daughter voiced some concern about the way Shahbaz (CNA #5) talks to Elder while she is trying to get her to eat. Daughter explained they were at the dining room table and stated what Shahbaz (CNA #5) had said, 'I don't care if your daughter is here or not you are going to eat.' Daughter explained that happened a few weeks ago on day shift. Daughter also explained that same Shahbaz (CNA #5) greeted her when her mom was coming back from hospital by telling her what another elder had said about her mom which she explained hurt her feelings. Daughter stated what Shahbaz (CNA #5) said 'Oh when they found out she was coming back- they said now we got to listen to her talk.'" On 11/8/13 at 8:55 a.m., the Administrator Designee stated that they did not suspend the Shahbaz (CNA #5). She was asked, "So she was allowed to work the next day?" The DON stated, "Yes." The Administrator Designee was asked. "Did you report this?" She stated "No." She was then asked, "Why not?" She replied, "I don't know, we should have." 5. On 11/7/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "H" when the facility implemented the following plan of removal. a. 11/2/13 Alleged Perpetrator was suspended pending investigation of this allegation. b. 11/2/13 DON and ADON began investigation conducting interviews with other residents and staff. c. 11/4/13 Began re-training staff with emphasis on reporting alleged abuse or neglect with Licensed Nursing staff being inserviced by Supervisor and being responsible for passing off to the LPN on next shift as staff reports t

Complaint # substantiated, all or in part, in these findings. Based on record review and interview, the facility's nursing administration failed to provide supervision of direct nursing care staff, to guide their interactions with residents and prevent them from following inappropriate instructions from the family member of 1 (Resident # 17) of 1 case mix resident who was the alleged victim of emotional abuse. This failed practice had the potential to affect 12 residents who resided in Cottage 6, according to the Roster Matrix provided by the Administrator on 9/9/13. The findings are: 1. The Director of Nursing (DON) job description received on 9/24/13 documented, "...The duties and responsibilities of the DON include: Visit each Green House home on a regular basis to monitor clinical care and status of the elders... Review nurse care plan compliance... Assure a program of staff development that supports high levels of staff skill... Discuss observations/concerns about clinical compliance with the CST nurses and/or Shabaz Care Coordinator as applicable based on the situation... Place issues/items for team discussion on the team meeting agenda, initial the entry, and seek feedback regarding the issues/items from the Team Coordinator after the meeting..." 2. Resident #17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/13 documented the resident scored a 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), had a poor appetite and trouble concentrating and required extensive assistance with eating. a. The Division of Medical Services form 762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long term Care Facilities, documented, "...Date Incident Reported to OLTC (Office of Long Term Care): 8/21/13 at 11:00 a.m., Date and Time of Incident (if known): 8/15/13 at 12:00 p.m., Date and Time of Discovery: 8/20/13 at 10:30 a.m... Emotional/Mental Abuse... Section II-Complete Description of Incident... It was reported by a Shabazz (specially trained direct care staff) that she witnessed another Shabazz talking to the Elder (Resident) and saying if she did not sit down and eat she (Shabazz) will call the police and they will put her outside." The Resident Plan of Care documented a problem dated 6/30/13 of, "Resident is at nutrition risk: related to: Failure to thrive. Disease process/condition (list); Dementia. Her appetite is fair. She would rather drink fluids than eat. She received supplements as ordered." There was no documentation on the care plan of an approach that involved threatening the resident to encourage her to eat. b. A OLTC Witness Statement Form documented, "August 20, 2013 (Shabazz (Certified Nursing Assistant (CNA) #10)) On August 15, 2013... while assisting her to the table, I told her to be quiet, sit down and eat her food." c. Additional OLTC Witness Statement Forms documented as follows: "8/20/13 (Elder) Yes, I've heard them say they was going to call the police. That's the only way they can get her to eat..." "8/21/13 (Shabazz (CNA #11))... Her daughter said to tell her whatever to get her to eat even if its saying call the police..." "8/21/13 (Licensed Practical Nurse (LPN #3)) ...have heard her daughter tell staff to tell her (resident) to eat cause (daughter's name) said so or to say (name) said so or (name) said so, with the last being police men here in (name of town)." "8/21/13 (Shabazz (CNA #12)) ...she (daughter) herself suggested that the ladies call her or (name). (Resident #17) then say's 'I'll eat honey don't call the police.' I just found out that (name) was a sheriff a long time ago and that's how she (daughter) got her mother to eat..." "8/21/13 (Shabazz (CNA #13)) ...Her daughter (name) say to tell her we are going to call (name) I never knew who he was until they say he's a police..." d. On 9/12/13 at 3:10 p.m., the Director of Nursing (DON) was asked, "Do you know where the witness statement is from the Shabazz who made the allegation?" She stated, "I'm not sure. I can ask (Administrator)." The names from the witness statements were read off to her and she stated, "No, it wasn't any of them. She was only here for a few days, I think." She was asked about the delay in reporting. She stated, "I don't really know. It may have been a weekend. I'm not sure how long she was here. She only worked a couple of days. I'm not over the Shabazz (CNA's)." She was asked, "You're not?" She stated, "No, (Administrator) is over the Shabazz. She does their schedule and oversees them and I'm over the LPN's. I'm over the more clinical side." e. On 9/12/13 at 3:40 p.m., the Administrator was asked for the witness statements from the Shabazz (CNA) who reported the allegation. She stated, "Everything should be in there." She reviewed the file and stated, "I'll look in my file." She stated, "I had to call her on the phone and ask her about it, because there was a rumor going on about this." She was asked what she meant by a rumor. She stated, "I heard that this Shabazz (CNA) was upset about this and so I called her." She was asked, "How did you hear about it?" She stated, "From another Shabazz. She told me about it so I called the other Shabazz." She stated "They were doing it because the daughter told them to do whatever it took." As of 9/13/13 at 2:00 p.m., no further Witness Statements were provided, including those from the two Shabazz that reported to the Administrator on 8/20/13. f. On 9/13/13 at 11:12 a.m., Certified Nursing Assistant (CNA) #10 was interviewed. She stated "Well, this is what happened. You know she won't eat, she wants to talk and leave the table. I told her be quiet and eat her dinner or I'd call the police. I never told her to shut up..."

Based on observation, record review and interview, the facility failed to ensure necessary care and services to address pain were provided, by failing to promptly offer and administer pain medication for 1 (Resident #9) of 5 (Residents #6, #7, #9, #11 and #13) case mix residents who had orders for as-needed (PRN) pain medication. This failed practice resulted in actual harm to Resident #9, who experienced unrelieved pain and decreased activity tolerance, and had the potential to affect 17 residents who had physician orders [REDACTED]. The findings are: Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/13 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had no scheduled pain medication, received as-needed pain medication and frequently experienced pain that limited daily activities and was rated 6 (out of 10) on the intensity rating scale. a. The September 2013 physician's orders [REDACTED]...4/15/13 [MEDICATION NAME] 7.5/500 mg (milligrams) po (by mouth) prn (as needed) 1 tab every 4 hours prn..." b. The Resident Plan of Care updated 7/16/13 documented, "...Disease Dx (diagnosis): Arthritis Resident c/o (complains of) pain to (left) LE (lower extremity) and hip. Goal: Resident will be free from complications r/t (related to) pain... Approaches 1) Adm (Administer) pain meds (medications) per MD (Medical Doctor) orders. 2). 09/10/13 (Change) to pain meds per MD orders..." c. A form titled "(Name of hospital) Discharge Instructions - ED (Emergency Department)" with an admission date of [DATE] documented, "...Discharge Instructions. Principal [DIAGNOSES REDACTED]. CT (Computed tomography) lower ext (extremity) Wo (without) contrast: ...Impression: 1. [MEDICAL CONDITION] changes in the left hip. 2. Joint effusion. 3. No acute fractures demonstrated... Knee 3 Views. Impression: [MEDICAL CONDITION] changes in the left knee with small effusion. No acute fractures seen..." d. The form titled "Pain Documentation" dated 9/10/13 documented, "...8:15 a.m., gave [MEDICATION NAME] 7.5 mg per orders... 9:50 a.m., Spoke (with) (MD). New order received. Will start when arrives from pharmacy..." e. A Physician's Telephone Order dated 9/10/13 at 10:30 a.m. documented, "..D/C (discontinue) [MEDICATION NAME] start [MEDICATION NAME] -10 Q (every) 4 hrs (hours) prn for px (pain)." f. On 9/10/13 at 4:18 p.m., the resident was sitting in a recliner in the TV area of the cottage, with his feet elevated. The resident stated he wanted to go to bed. Certified Nursing Assistants (CNA's) #5 and #6 went to assist him from the recliner to the wheelchair. When the footrest of the recliner was moved down, the resident was very anxious and stated, "Whoa, whoa whoa!" and held onto the armrest of the recliner. CNA's #5 and #6 moved the footrest slowly downward. The wheelchair was placed on the left (affected) side of the resident. A gait belt was placed around the resident's waist. The resident was very anxious and complained of pain. CNA #5 and #6 talked with the resident and allowed time for the resident. He continued to complain of pain in his left leg. At 4:25 p.m., Licensed Practical Nurse (LPN) #1 came to the TV area and talked with the staff and the resident. She stated, "We're waiting for his new medication to come in from the pharmacy." At 4:35 p.m., the resident was still unable to move from the recliner to the wheelchair, due to pain in his left leg. Registered Nurse (RN) #1 asked the resident "Are you ready to transfer?" The staff were asked by the surveyor if the wheelchair might need to be moved to the right side, as the resident continued to complain of pain to the left knee and left hip. The wheelchair was moved to the right side of the resident. The resident continued to complain of pain and was anxious when the staff made movements to assist him. He stated, "It hurts too bad." The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated She's (LPN #1 is) waiting for the pharmacy to bring his new med." At 4:58 p.m., the resident was still in the recliner and attempting to get in to the wheelchair, so that he could be put to bed; however, due to pain in the left hip and knee, he was not able to stand or attempt to stand. The resident continued to grab his left thigh with any movement. At 5:08 p.m., the resident was still in the recliner and stated, "I'm okay as long as I'm still." RN #1 offered the resident supper and he stated, "I'm not hungry." He was offered a drink. At 5:17 p.m., the resident continued to have pain to the left thigh and leg and was unable to move. The staff was serving supper to the other residents. This resident remained in the recliner. The surveyor left the cottage and returned at 5:23 p.m. At that time, the resident was in his wheelchair sitting next to his bed with CNA #5 and #6 in the room with the resident. CNA #5 and #6 transferred the resident from the wheelchair to the side of his bed with use of a gait belt. The resident was in pain during the transfer to the bed. He was pivoted toward the left (affected) side. He was unable to move up in the bed due to pain in the left thigh. He would put his fists down on the bed to lift his weight up slightly and would then grab his left thigh. He continued to try to scoot backward or toward the head of the bed but was unable to move due to pain. At 5:35 p.m., LPN #1 came into the resident's room and asked CNA #5 and #6 if it was going to be much longer for them and they stated, "Yes", because the resident was unable to move up or back into the bed. LPN #1 asked the resident "Do you want your pain pill now?" LPN #1 told the surveyor, "I asked him a few minutes ago and he told me no." The resident stated, "I'll take a couple of them." At 5:38 p.m., LPN #1 brought the resident a pain pill. She was asked if this was the new dose and she stated, "No, we're waiting for it to come in. We've called and faxed." The back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. LPN #1 and CNA #5 continued to work with the resident to try to get him from sitting on the side of the bed to lay down in the bed. He continued to complain of pain and grab his left thigh when slightly moved. At 5:48 p.m., LPN #1 stated, "I'll call (DON)" and she left the room. At 5:52 p.m., LPN #1 stated, "I left a message for (DON). (RN #1) is coming down." At 5:55 p.m., RN #1 entered the cottage and went to the resident's room. At 6:25 p.m., the resident was lying in his bed. The resident's supper tray was sitting untouched on the over-the-bed table in his room. The resident was still uncomfortable, exhibited by tense posture, holding onto the side rail and furrowed brow. He stated, "I'm a little better now."

Based on observation, record review and interview, the facility failed to ensure acceptable parameters of nutritional status was maintained for Resident #s 2, 5 and 10. The facility failed to ensure planned interventions to address severe weight loss and prevent continued weight loss were consistently implemented and feeding assistance was provided for 3 (Residents #2, 5 and 10) of 4 (Residents #2, 5, 10 and 17) case mix residents who required assistance with meals, had a history of [REDACTED]. The failed practice resulted in a pattern of harm for Residents #2 and 5, who experienced severe, unplanned weight loss, and was likely to cause more than minimal harm for 6 residents who resided in Cottage 6 who required extensive to total assistance with eating according to a list provided by the Administrator on 10/14/11. The findings are: 1. Resident #2 resided in Cottage 6 and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/6/11 documented the resident scored 5 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with eating and had a weight of 144 pounds based on the most recent measure in last 30 days. a. The facility weight log documented the following monthly weights from July 2011 through September 2011: July 2011 - 144.5 pounds (lbs.) August 2011 - 136.5 lbs. September 2011 - 133.5 lbs. b. The Care Plan with a review date of 8/3/11 documented, " Elder is at nutrition risk as evidenced by needs assistance with meals ...Approaches: Weight and monitor results monthly and PRN (as needed). Signs and Symptoms of nutritional support as ordered ...8/18/11 supplement added ... " c. Dietary Progress Note dated 8/24/11 documented " Wt (weight) 8/11- 136.5 # (pounds), (decrease) 8# (5.5%) in 1 mo (month), (decrease) 7.27% in 6 mo ...Diet: Puree, NAS (no added salt) order noted 8/19/11 for Benecal (with) lunch (and) dinner. Receives 2 cal- 4 oz (ounces) (with) med pass and Ensure Plus at 10 -2- HS (10:00 a.m., 2:00 p.m. and Bedtime). Will ask if elder needs help (with) meals ... " Dietary Progress Note dated 9/12/11 - Wt 9/11 - 133.5#, (decrease) 3# (2.2%) in 1 month, (decreased) 4.5 % in 3 mo, (decreased) 3.5% in 6 mo. Elder initially tried to feed herself (and) later fed. She does appear to need help (with) feeding ... " d. A physician's orders [REDACTED]." e. The Weight Log documented the resident's weight for October 2011 was 132 lbs. This represented an additional 1.5 pounds lost since September 2011, for a total of 12.5 pounds (8.65%) in a 3-month period. f. On 10/11/11 at 8:36 a.m., during the 8:00 a.m. medication pass, Licensed Practical Nurse #4 gave the resident 6 ounces of a pink liquid (unknown) to drink with medication pass and 6 ounces of water. The resident consumed 100% of the fluids offered. g. On 10/11/11 at 9:00 a.m., the resident was seated at the dining room table and was served pureed eggs, meat, and a scoop of oatmeal. There was one Certified Nurse Assistant (CNA) serving the meal and the other CNAs were busy with other residents, leaving this resident without assistance. The resident would put her fingers in the food and try to get the food to her mouth, but was not successful. 1) At 9:02 a.m., the resident was served a bowl of something that looked like a biscuit with milk poured over it. The resident attempted to feed self the liquid from the bowl but was unsuccessful. The resident began to cry and stated, "I'm so hungry." 2) At 9:04 a.m., the resident was served 8 ounces of punch. The resident tried to get food onto a spoon, but was not successful. After repeated unsuccessful attempts to feed herself, the resident put her head onto the table and began to cry. 3) At 9:12 a.m., Certified Nursing Assistant #5 sat down beside the resident and began to feed her. The resident ate and kept repeating "...so good... so good..." There was no super cereal on the resident's tray as ordered. h. On 10/11/11 at 11:00 a.m., the resident had not been out of the surveyor's line of sight since 9:00 a.m. The resident was not given the 8 ounces of Ensure Plus that was to be served at 10:00 a.m. When asked if the resident had been served the Ensure Plus, CNA #4 stated, "No." i. On 10/11/11 at 2:20 p.m., the resident was assisted to bed by CNA #4 and #6 . At 6:10 p.m., the resident was still in her bed. The supper meal service time was 5:30 p.m. At 6:25 p.m., as CNAs #8 and #10 were cleaning up the dining room table and kitchen, they were informed the resident had not been gotten up and fed the supper meal. The resident refused to eat when the CAN#8 entered the room with tray. j. On 10/12/11 at 9:16 a.m., the resident was served pureed eggs, sausage, an 8 ounce glass of orange juice, pureed biscuit and a pureed blueberry muffin. CNA #4 assisted the resident with breakfast. There was no super cereal served with the meal. k. On 10/12/11 at 10:30 a.m. the resident had not been out of the surveyor's line of sight since 9:16 a.m., the resident was reclined in her geri-chair with her legs elevated. The resident was not given the 10:00 a.m. Ensure Plus. 2. Resident #5 resided in Cottage 6 and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/25/11 documented the resident scored 4 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, had a weight of 150 pounds based on the most recent measure in the last 30 days and required extensive assistance of one with eating. a. The facility Weight Log documented the following monthly weights from July 2011 through October 2011: July 2011 - 165.4 lbs August 2011 - 156.0 lbs. September 2011 - 150.2 lbs. October 2011 - 147.2 lbs This was a severe weight loss of 18.2 lbs (11%) in a 3-month period. b. The Care Plan with a review date of 9/26/11 documented, " Nutrition: Mechanical Altered diet changed to Regular diet on 7/1/11. 8/11/11 wt loss noted. 9/23/11 dietician ordered. ...Approaches 8/18/11 Supplements added. 8/31/11 Supplements added. 9/1/11 - Supplements added. 9/23/11 - Super Cereal ...1/2 sandwich (at) 10 (10:00 a.m.) and 2 (2:00 p.m.). 9/23/11 Supplements as ordered. 9/26 Mechanical Soft diet. " c. A Physician order [REDACTED].? sandwich at 1000 and 1400 (10:00 p.m. and 2:00p.m.). " The order was also on the current Physicians Orders sheet, October 2011. d. On 10/10/11 at 5:43 p.m. during the supper meal, the resident was served a hamburger patty with a bun, a slice of tomato, sweet potato tots, a banana and a cookie. The only condiment served was mayonnaise in a plastic packet. The resident was served 8 ounces of punch and drank without assistance. The resident's mayonnaise was never opened, the hamburger was never assembled and the resident was not offered any more liquids. The resident would or could not feed herself and was not assisted. e. On 10/11/11 at 9:08 a.m., the resident was in sight by the surveyor from 9:03 a.m. through 11:25 a.m. The following observations were made: At 9:08 the resident was served breakfast. CNA #5 was asked if the resident had been served super cereal. The CNA stated, "No." The resident was not assisted with breakfast and did not eat anything. At 10:00 a.m., the resident was seated in the living area of Cottage 6. The resident was not given a 10:00 a.m. sandwich snack. f. On 10/11/11 from 2:00 p.m. to 2:40 p.m., the resident was not out of the surveyor's line of sight. The resident was never given a 2:00 p.m. snack. g. On 10/12/11 at 9:10 a.m., the resident was served breakfast. The resident was served sausage patty, scrambled egg, biscuit, small blueberry muffin, 8 ounce glass of orange juice. At 9:17 a.m., the resident was served 6 ounces of carnation instant breakfast. CNA #9 was asked if they had fixed supercereal for the resident, she stated, " No. " h. On 10/12/11 the resident was in the surveyor line of sight from 9:30 a.m. through 11:30 a.m. , the resident did not receive a 10:00 a.m. snack. 3. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/18/11 documented the resident scored 2 ( 0-7 indicates severely impaired) on the Brief Interview for Mental Status, required extensive assistance with eating and had a weight of 108 pounds based on the most recent measure within the last 30 days. a. The facility Monthly weight log documented the resident weight for August was 113.8 and for September 108.4. A list of resident weights received from the Administrator on 10/12/11 at 2:45 p.m. documented the resident ' s weight was 105.4 for October 2011. a. The Care Plan dated reviewed 9/19/11 documented, " (handwritten) ADL ' s (Activities of daily living) ...eating- extensive assist (assistance) x 1. " b. The October 2011 physician's orders [REDACTED]. " c. A Physician order [REDACTED]." b. On 10/11/11 at 5:20 p.m., the resident was seated in the dining room at the end of the table. The resident was served her meal with no beverages. At 6:14 p.m., CNA #8 attempted to assist the resident with the meal. The resident would not eat. The resident was not served the ice cream or Magic Cup. c. On 10/12/11 at 9:03 a.m., the resident was seated at the dining room table in Cottage 6, fluids were served at 9:03 a.m. and the resident's meal was served at 9:09 a.m. The resident did not initiate any attempts to feed herself. At 9:33 a.m., CNA #7 sat down beside the resident and attempted to assist the resident with her meal. The food was cold and the CNA did not reheat the food or get more for the resident. The resident was not served a Magic Cup and the resident would not eat what was being offered. d. On 10/12/11 from 9:50 to 10:30 a.m., the resident was not out of the surveyor's line of sight. The resident did not receive her 10:00 a.m. snack.

Based on observation, record review and interview, the facility failed to ensure assistance with activities of daily living (ADL's) were provided for Residents #2, #5 and #10 in order to maintain the highest practicable well-being, as evidenced by: failure to ensure residents were checked for incontinence and provided with incontinent care promptly to promote good hygiene and prevent odors for 3 (Residents #2, #5 and #10) of 6 (Residents #2, 5, 6, 10, 14 and 17) case mix residents who resided in Cottage 6 and were incontinent of bowel or bladder; failure to ensure urine/feces were cleansed from all areas of the skin to promote good hygiene and prevent odors for 1 (Resident #5) of 4 (Residents #2, 5, 6, and 10) case mix residents who resided in Cottage 6 and were incontinent of bowel or bladder, and; failure to ensure dried food was cleansed from residents' face promptly after meals to promote good hygiene for 3 (Residents #2, 5 and 10) of 6 (Residents #2, 5, 6, 10, 14 and 17) case mix residents who required assistance with personal hygiene and resided in Cottage 6. The failed practices were likely to affect 10 residents who required total to extensive assistance with personal hygiene, and 10 residents who resided in Cottage 6 who were incontinent of bowel or bladder, as documented on a list provided by the Administrator dated 10/14/11. The findings are: 1. Resident #2 resided in Cottage 6, had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/6/11 documented the resident scored 5 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was incontinent and required total assistance with personal hygiene. a. The Care Plan with a review date of 8/3/11 documented, " Elder is experiencing incontinent episode of bowel and/or bladder. ...Approaches ...Provide prompt peri-care PRN (as needed) for incontinent episodes between regularly scheduled toileting times. ...Monitor for non-verbal cues that the resident may need to use the toilet outside of the regular toileting schedule, and provide assistance PRN to toilet. " b. On 10/11/11 at 12:42 p.m., during the noon meal, the resident was served pureed barbequed meat, barbequed beans and potato salad. The resident began to cry and eat with her fingers. At 12:46 p.m., Certified Nurse Assistant (CAN) #6 sat down beside the resident to feed her. The resident had a good appetite. At 2:20 p.m., the resident was assisted to bed by CNA's #4 and 6. After the resident's incontinent care was completed, the CNA's collected the soiled linen, washed their hands and left the room. The resident had residue from the barbequed beans all around her mouth that had dried. At 6:10 p.m., the resident remained in her room in bed. The dried residue from the barbequed meal at 12:42 p.m. was still on the resident's face around her mouth. l. On 10/12/11 between 8:30 a.m. and 9:50 a.m., the resident was seated in a geri-chair in the dining area and living area which is adjacent to the dining area in the cottage. The geri-chair was reclined with the resident's legs elevated and she was covered with a blanket. The resident had been in the surveyor's line of sight since 8:30 a.m. At 11:30 a.m., the resident remained in the geri chair in the living area. CNA #4 and 7 were asked if the resident had been checked for incontinence since they had gotten the resident up for breakfast at 8:30 a.m. They both stated, "No, we are going to." 2. Resident #5 who resided in Cottage 6 and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/25/11 documented the resident scored 4 (0-7 indicates severely impaired) on the Brief Interview for Mental Status and required extensive assistance of one with eating. a. The Care Plan with a review date of 9/26/11 documented, " Elder is experiencing incontinent episodes of Bowel and/or Bladder. Elder is occasionally incontinent. Extensive assistance x 21 for toileting. ...Approaches ...Provide prompt peri-care PRN for incontinent episodes between regularly scheduled toileting times. ...Adjust toileting schedule PRN if the elders elimination pattern change. Monitor for nonverbal clues that the elder may need to use the toilet outside of the regular toileting schedule, and provide assistance PRN to toilet. " b. On 10/11/11 at 2:15 p.m. the resident was in her room and in bed. The resident had sauce from the noon meal all around her mouth and on her face. At 2:40 p.m., CNA #4 and 6 provided incontinent care. The resident had been incontinent of stool. The resident was turned onto her right side and was cleansed, then turned on her back and the perineal area was cleansed. The resident was never turned on her left side to have the right buttock cleansed. After the incontinent care was completed, CNAs #4 and 6 exited the room. The resident still had the dried sauce all over her face. c. On 10/12/11, the resident was continuously observed by the surveyor from 8:05 a.m. to 11:30 p.m. At 11:30 a.m., CNAs #4 and 6 were asked if the resident had been checked for incontinence since she had been gotten up that morning. They both stated, "No, we have been so busy." 3. Resident #10 resided in Cottage 6 and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/18/11 documented the resident scored 2 ( 0-7 indicates severely impaired) on the Brief Interview for Mental Status, required extensive assistance of two staff member with incontinent care. a. On 10/12/11 at 9:03 a.m., the resident was seated at the dining room table in Cottage 6. The fluids were served at 9:03 a.m. and the meal was served at 9:09 a.m. The resident did not initiate any attempt at feeding herself. At 9:33 a.m., CNA #7 sat down beside the resident and attempted to assist her with the meal. The food was cold but the CNA did not reheat the food or get more. The resident would not eat. b. On 10/12/11 at 11:30 a.m., the resident had not been out of the surveyor's line of sight since 9:03 a.m. CNAs #4 and 7 were asked if the resident had been checked for incontinence since they had gotten her up and brought to the dining room at 8:55 a.m. They both stated, "No, we have been busy - trying to..."