**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to protect the resident's right to be free from abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, a Certified Nursing Assistant (CNA) reported to a Licensed Nurse Supervisor that Resident #7 was found in bed with a sheet tied across her midsection and fastened to the bedframe. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Nursing Home Administrator (NHA), who also served as the facility's Abuse Coordinator. The facility failed to implement a systematic process to carry out their abuse policy for Resident #7, a cognitively impaired resident who was dependent on staff for all care and services. The facility failed to identify the incident as abuse. The facility failed to take actions to report, thoroughly investigate, protect Resident #7, and take corrective action to determine the root cause of the abuse to ensure all facility residents would remain safe from a similar incident. This resulted in findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference F609, F610, and F835 On 11/01/2022 at 1:41 p.m., during an interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. On 10/31/2022 at 1:00 p.m., Staff D, LPN confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/UM] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for. She has dementia. On 10/31/2022 at 11:38 a.m., an attempt was made to interview Resident #7. She was observed lying in her bed in her room. The television was on and no restraints were visible. Resident #7 was alert and her eyes were open. She made eye contact when addressed but did not respond verbally to simple questions. She closed her eyes during the visit and appeared to fall asleep. Review of Resident #7's medical record was conducted on 10/31/2022. The admission record revealed the resident was [AGE] years old and originally admitted to the facility on [DATE]. Diagnoses listed on the admission record included: hemiplegia and hemiparesis (partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction, aphasia (loss of ability to express or understand speech) following cerebral infarction, unspecified dementia without behavioral disturbance, gastrostomy (feeding tube) status, cognitive communication deficit, unspecified mood disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a diabetic foot ulcer, no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed: A focus area, initiated on 7/22/2022 and last revised on 7/28/2022, for alteration in her ability to perform self-care tasks related to weakness, impaired mobility and cognition, which required extensive assistance during Activities of Daily Living (ADL) tasks. Interventions included Staff to maintain [Resident #7's] safety and dignity while assisting her during ADL tasks. A focus area, initiated on 8/9/2022 and revised on 10/29/22, for exhibiting inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected. Interventions included: anticipate and meet the resident's needs (created 8/10/2022); caregivers to provide opportunity for positive interaction, attention (created 8/10/2022); intervene as necessary to protect the rights and safety of others (created 8/10/2022); and resident prefers to keep clothing on while in bed (initiated by the DON on 10/25/2022). A focus area, initiated and revised on 7/28/2022, for impaired cognitive function and/or impaired thought process related diagnoses of dementia, disorientation to place, time and situation. Resident #7 is oriented to person, aphasic (mumbled speech), and speaks mostly Spanish which is an additional risk factor. Resident is sometimes understood and sometimes understands others. Interventions included: cue, reorient and supervise as needed; defer to Spanish speaking staff and/or family to assist with communication during times when resident reverts back to native language; and keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. A focus area, initiated and revised on 7/28/2022, for risk of falling related to weakness, impaired mobility, and cognition related to diagnoses of cerebral infarction with subsequent right sided hemiparesis and dementia. Interventions included: be sure the resident's call light is within reach on her left side and encourage the resident to use for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the progress notes for October 2022 revealed an entry dated 10/25/22 5:00 p.m. titled Skin/Wound Note authored by the NHA. The note read: This writer spoke with Resident #7's niece regarding resident's plan of care (POC). Res[ident] continues to be fidgety moving in/out of bed. Discussed alternatives such as psych interventions, reiterated facility is restraint free environment. Niece agrees with POC. Informed her of new open area on right lateral ankle identified earlier today. Treatment in place and wound care consultant scheduled for visit tomorrow. Niece consents/agrees with psych and wound consult. She reported son visited yesterday. No other issues or concerns identified. She plans to attend next care plan meeting as per usual schedule. There was another entry dated 10/25/22 3:26 p.m. authored by the DON and Staff C, LPN, UM titled, Skin Only that read: Skin Evaluation: Skin warm & dry, skin color WNL [within normal limits] .Resident has current skin issues. Skin Issue: Pressure Ulcer/Injury. Skin issue location: Right lateral ankle Pressure Ulcer/Injury Stage: Stage II - Partial thickness skin loss. Length: 2cm [centimeter] Width: 2cm Depth: 0cm . Skin Issue: Moisture Associated Skin Damage (MASD). Skin issue location: left flank . On 10/31/2022 the medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. Review of facility log titled Incidents By Incident Type was conducted on 10/31/2022. The log did not reveal any entries related to Resident #7 on 10/25/2022. Review of facility log titled Abuse/Adverse Event Log was conducted on 10/31 /2022. The log for October 2022 did not reveal any entries related to Resident #7. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H/CNA was suspended pending investigation but said Staff I/LPN and Staff J/LPN were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA said, there was never any indication from [Resident #7's niece] that she thought this was abuse related. The NHA stated the facility's Social Services Director (SSD) did a trauma assessment and said, and I think also a BIMS assessment. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. On 10/31/2022 at 5:00 p.m., a follow-up interview with the NHA revealed the SSD performed a psychosocial assessment on the wrong resident (another resident in the facility with the same last name), which was why it wasn't documented in Resident #7's medical record. She stated the consultant psychiatric provider did see Resident. #7 in response to the incident. The NHA stated she would provide the psychiatric note once it was sent over from the provider. On 11/02/2022 at 10:28 a.m., the SSD reported she was aware of the restraint incident involving Resident #7 on 10/25/2022. She confirmed she was informed about the incident by the DON either the same day (10/25/2022) or the next day (10/26/2022). The SSD said, I was asked to do an assessment on her including BIMS and trauma assessment, but she [the DON] told me the wrong person. She told me [another resident's name] instead of [Resident #7] so I did a BIMS on [other resident]. I went back and let them [the NHA and DON] know I had done the BIMS, didn't think to tell her name. The next day in morning meeting, they asked did I do the BIMS because they couldn't find it. That's when they clarified that it was Resident #7 . they said they directed me to do it after the clarification, but that's not what I understood. The SSD confirmed she had never completed any assessment of Resident #7 related to the incident on 10/25/2022 and said she had not conducted or documented any assessments on Resident #7 since beginning employment at the facility around 09/25/2022. Review of facility policy titled Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI (Quality Assurance and Performance Improvement) program. 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. II. Employee Training A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in dash services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, Neglect, Exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect, such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and\or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned. Have knowledge of the individual resident's care needs and behavioral symptoms; D. The identification, ongoing assessment, care, planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. exercising caution and handling evidence that could be used in a criminal investigation. (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and\or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Reporting/Response A. The facility will have written procedures that include.: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse . or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime . 5 Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and\or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. VIII. Coordination with QAPI A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. 1. Cases of physical or sexual abuse, for example by facility staff or other residents,

Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to take action to promptly report abuse of one (Resident #7) of three residents reviewed for abuse. On 10/25/2022 a nursing staff member reported to their superior that they found Resident #7 in her bed with a sheet tied across her midsection and fastened to the bedframe during performance of morning care tasks. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA). Resident #7 was a cognitively and physically impaired individual who had a communication deficit and was dependent on facility staff for all care and services. The facility's failure to report the incident in accordance with the regulations and the facility's abuse policy and procedure placed this resident and other residents at risk from a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, serious psychosocial harm (using the psychosocial severity guide), serious impairment or death due to ligature risk and resulted in findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference to F600, F610, and F835 Review of facility policy titled, Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of an unknown source 4. Resident reports of theft of property, or missing property 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; 5. Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. On 11/01/2022 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. On 10/31/2022 at 1:00 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/Unit Manager (UM)] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for. She has dementia. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. Review of facility log titled Incidents By Incident Type and the Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs did not reveal any entries related to Resident #7 in October 2022. Review of Resident #7's medical record was conducted on 10/31/2022. Diagnoses listed on the admission record included: hemiplegia and hemiparesis (partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction, aphasia (loss of ability to express or understand speech) following cerebral infarction, unspecified dementia without behavioral disturbance, gastrostomy (feeding tube), cognitive communication deficit, unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a diabetic foot ulcer, no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed she required extensive assistance during Activities of Daily Living (ADL) tasks; exhibited inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected; had impaired cognitive function, oriented to person only, and had impaired communication abilities both for understanding others and making herself understood; and was at risk for falls related to weakness, impaired mobility, and diagnoses of cerebral infarction with subsequent right sided hemiparesis and dementia. Review of the progress notes for October 2022 revealed an entry dated 10/25/22 5:00 p.m. titled Skin/Wound Note authored by the NHA. The note read: This writer spoke with Resident #7's niece regarding resident's plan of care (POC). Res[ident] continues to be fidgety moving in/out of bed. Discussed alternatives such as psych interventions, reiterated facility is restraint free environment. Niece agrees with POC. Informed her of new open area on right lateral ankle identified earlier today. Treatment in place and wound care consultant scheduled for visit tomorrow. Niece consents/agrees with psych and wound consult. She reported son visited yesterday. No other issues or concerns identified . There was another entry dated 10/25/22 3:26 p.m. authored by the DON and Staff C, LPN, UM titled, Skin Only that read: Skin Evaluation: Skin warm & dry, skin color WNL [within normal limits] .Resident has current skin issues. Skin Issue: Pressure Ulcer/Injury. Skin issue location: Right lateral ankle Pressure Ulcer/Injury Stage: Stage II - Partial thickness skin loss. Length: 2cm [centimeter] Width: 2cm Depth: 0cm . Skin Issue: Moisture Associated Skin Damage (MASD). Skin issue location: left flank . On 10/31/22, Resident #7's medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H/CNA was suspended pending investigation but said Staff I/LPN and Staff J/LPN were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. On 11/02/2022 at 10:25 a.m., a telephone interview was conducted with Staff H, CNA. She confirmed she had worked both the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift from 10/24/2022 - 10/25/2022. She confirmed she was assigned care for Resident #7 for both shifts. She stated she had been a permanent employee at the facility since June 2022 and typically worked the 3:00 p.m. - 11:00 p.m. shift. Staff H said, [Resident #7] likes to dig in her diaper. She pull her diaper off. She pulls at her feeding tube. She digs in her poop. She'll look at you, she'll smile, she screams, she cries, all communication is unintelligible. Staff H stated Resident #7 was not able to make her basic needs known or respond to basic questions. She stated Resident #7 was dependent on facility staff for everything. Staff needed to anticipate her needs, provide all levels of care, and required a mechanical lift for transfers out of bed. Staff H stated she started her shift on 10/24/2022 at about 2:45 p.m. and she did her last resident rounds on 10/25/2022 at about 4:45 a.m. She reported that after she completes her final rounds she does her charting. Staff H thought she clocked out around 7:30 a.m. on 10/25/2022. Staff H reported she changed the resident during both shifts and said, my last rounding and care with [Resident #7] was a little bit after 5 a.m. She was in the bed, did not see a restraint at that time. Staff H said, I never saw that restraint on the resident at any time. Staff H stated she had never received any training on restraint use or abuse at any time from the facility. Staff H confirmed she was no longer employed by the facility and said, they terminated me because I wouldn't write a statement, but by law I don't have to write a statement . On 11/01/2022 at 11:31 a.m., Resident #7's Primary Care Physician (PCP) confirmed he was notified Resident #7 was found tied to her bed with a sheet. He said, it was last Tuesday [10/25/2022], they told me, and I was here in the building. [The DON] told me about it. He said, I inquired if they informed the family and they said they did. He stated he recommended the facility conduct a care plan meeting with the family. The PCP said, I was not a part of the investigation or any other steps because I am not the Medical Director here. The PCP said, I assessed the resident that day. She is nonverbal. I examined her. There were no bruises or marks on the body, vitals were normal. Regarding documentation for that visit the PCP said, I did not document that visit, don't always document all my visits. The PCP stated, restraints should not happen; we cannot do it legally. On 11/01/2022 at 9:30 a.m. the NHA provided a typed summary of the facility's investigation actions. She stated that when she had reviewed the investigation notes and the typed summary after being interviewed on 10/31/2022, she did not discover any additional steps in their investigation that had not already been shared. She confirmed the typed summary was comprehensive and there was nothing additional. She stated Resident #7 was someone who was not able to move and not able to get out of bed. She stated the restraint had not impacted on Resident #7's mobility, had not caused any physical injury or psychosocial harm, and therefore their findings were that no abuse had occurred, and nothing rose to the level of needing to be reported. Review of the typed investigation summary provided by the NHA on 11/01/2022 at 9:30 a.m. revealed: Based on the record review, staff interviews, resident observation and skin evaluation, there is no reason to believe this meets the definition of abuse. There does not appear to be any skin discoloration, injury, pain or psychological distress related to the situation. Unreasonable confinement was also not of concern as staff reported resident still had mobility in bed and movement was not restricted side to side. Although the root cause/purpose of the sheet being tied to the bed frame cannot be identified, it does not appear to be willfully inflicted on the resident. There is no data or evidence to indicate that the resident was harmed in any way or that harm was intended. Corrective action taken: 1. Skin evaluation completed for [Resident #7]. 2. [Staff H], CNA suspended pending investigation. She failed to cooperate with the investigation as she refused to provide a written statement. Her employment was terminated as a result of her insubordination and failure to cooperate with an ongoing investigation. 3. Informed attending MD (medical doctor) and Medical Director 4. [name of niece], niece, informed and aware of situation. 5. Audit: no other residents were identified as having a sheet tied across their abdomen. 6. Review with Regional Nurse Consultant/Regional Director of Operations. 7. DON initiated staff education re [regarding]: restraints. Staff were able to describe types of restraints. 8. Psychiatric ARNP [Advanced Registered Nurse Practitioner] was consulted on 10/27/22. Resident was determined to be at baseline, no changes needed. 9. [Resident #7's] normal body movement was not constricted in any way with the sheet tied across her abdomen. At her baseline, she is not ambulatory and cannot get out of bed. Staff interview revealed that [Resident #7] was still able to have mobility in the bed side to side. There was no skin issue, psychological distress or pain/harm caused secondary to the sheet. On 11/01/2022 at 1:28 p.m., a telephone interview with the facility's Medical Director confirmed the facility informed him of the restraint incident with Resident #7. The Medical Director said, I think they notified me afterwards because they didn't think it was a reportable incident. They notified me a few days later in morning meeting. The Medical Director stated the restraint was described to him as loosely tied. He said, we bantered this around, was almost like trying to make an analogy of a person in a wheelchair who was mobile and putting a laptop or safety belt around them, that would impede their mobility and be considered a restraint. But [Resident #7], I looked at her case, someone bedbound, total care, couldn't move, didn't look good but didn't impede mobility in reality. Regarding whether psychosocial impact was discussed he said, I don't think that came up, no, but that's a good point. He then stated, I think someone said her BIMS was basically zero meaning she wasn't alert and aware of her surroundings so because of that I wouldn't have been worried about psychosocial impact but if she had been alert and aware, I would have been concerned about that. The Medical Director stated he was not asked to participate in an investigation. He said, I don't know if they're done with their investigation, I know they were talking to some people, I don't know the outcome. The Medical Director stated there had been no QA process or meeting related to the incident that he was involved in and said, Our QA is coming up this Thursday so I'm sure it will come up. An interview was conducted with the NHA on 11/02/2022 at 2:00 p.m. She confirmed as of that date and time still no reporting had been done regarding the restraint incident with Resident #7 on 10/25/2022. Regarding how determinations were made on which incidents required reporting to law enforcement she stated the facility followed the elder abuse law and reported incidents when there was a possible crime such a misappropriation or abuse with injury. When asked to explain further she said, I'd have to consult the policy. An interview was conducted with the NHA, DON, and the RNC on 11/02/2022 at 4:07 p.m. The NHA stated that earlier that afternoon she had reported an allegation of abuse related to the incident with Resident #7 on 10/25/2022. She stated she had reported it to the Department of Children and Families (DCF), law enforcement, Resident #7's niece, and filed an immediate federal report to the state agency. She stated the decision to report was because she had received a progress note on 11/02/2022 from Resident #7's PCP for a service date of

Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's medical director, it was determined the facility failed to conduct a thorough investigation in response to allegations of witnessed abuse and mistreatment for one (Resident #7) of three residents reviewed for abuse, failed to protect one (Resident #7) of three residents reviewed for abuse from further abuse and mistreatment, and failed to implement corrective action in a timely manner to protect all facility residents from a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, serious psychosocial harm (using the psychosocial severity guide), or serious impairment or death due to ligature risk. On 10/25/2022, a Certified Nursing Assistant (CNA) reported to their superior that Resident #7 was found in bed with a sheet tied across her midsection and fastened to the bedframe during performance of morning care tasks. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA), who also serves as the Abuse Coordinator. Resident #7 was a cognitively and physically impaired individual who had a communication deficit and was dependent on facility staff for all care and services. The facility's failure resulted in the findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference F600, F609, and F835 Review of the facility policy titled, Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Response A. The facility will have written procedures that include.: 5 Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and\or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. A telephone interview with Resident #7's niece on 11/01/2022 at 11:57 a.m. revealed she was contacted on 10/25/2022 by the NHA about a restraint. She stated the time of contact was around 4:54 p.m. She said, [NHA]) told me hey [Resident #7's] okay. There's no harm, but she just wanted to give me a rundown on what happened, that there's a policy or law about no restraints and it was brought to her attention that someone restrained my aunt. I asked restraints how? Did they tie her legs and arms to the rails? And she goes, no her arms and legs were not bonded. I think she said there was like a cover tied over her but her arms and legs were not. [NHA] told me that they found who the employee was and they were reprimanded. An interview was conducted with Resident #7's PCP on 11/01/2022 at 11:31 a.m. He confirmed he was made aware that Resident #7 was found tied to her bed with a sheet. Regarding when he was informed he said, it was last Tuesday, they told me and I was here in the building, [The DON] told me about it. He said, I inquired if they informed the family and they said they did. He stated he recommended the facility conduct a care plan meeting with the family. The PCP said, I was not a part of the investigation or any other steps because I am not the Medical Director here. Regarding whether he assessed Resident #7 post-incident on 10/25/2022 he said, I assessed the resident that day, she is nonverbal, I examined here, there were no bruises or marks on the body, vitals were normal. Regarding documentation for that visit the PCP said, I did not document that visit, don't always document all my visits. Regarding his thoughts about the findings of the Resident tied to her bed with a sheet he stated his thoughts were that should not happen and said, restraints should not happen, we cannot do it legally. Review of the facility logs titled Incidents By Incident Type and Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs revealed no entries related to Resident #7 for October of 2022. Review of Resident #7's medical record on 10/31/2022 revealed an admission record with diagnoses to include: hemiplegia and hemiparesis (partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction, aphasia (loss of ability to express or understand speech) following cerebral infarction, unspecified dementia without behavioral disturbance, gastrostomy (feeding tube) status, cognitive communication deficit, unspecified mood disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a diabetic foot ulcer, no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed: A focus area, initiated on 7/22/2022 and last revised on 7/28/2022, for alteration in her ability to perform self-care tasks related to weakness, impaired mobility and cognition, which required extensive assistance during Activities of Daily Living (ADL) tasks. Interventions included Staff to maintain [Resident #7's] safety and dignity while assisting her during ADL tasks. A focus area, initiated on 8/9/2022 and revised on 10/29/22, for exhibiting inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected. Interventions included: anticipate and meet the resident's needs (created 8/10/2022); caregivers to provide opportunity for positive interaction, attention (created 8/10/2022); intervene as necessary to protect the rights and safety of others (created 8/10/2022); and resident prefers to keep clothing on while in bed (initiated by the DON on 10/25/2022). On 10/31/2022 the medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. On 10/31/2022 at 11:38 a.m., an attempt was made to interview Resident #7. She was observed lying in her bed in her room. The television was on and no restraints were visible. Resident #7 was alert and her eyes were open. She made eye contact when addressed but did not respond verbally to simple questions. She closed her eyes during the visit and appeared to fall asleep. On 11/01/2022 at 1:41 p.m., during interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. Review of timecards revealed Staff E, CNA clocked in at 8:30 a.m. on 10/25/2022. Review of CNA task documentation in Resident #7's medical record revealed eating was charted by Staff E, CNA on 10/25/2022 at 9:00 a.m. On 10/31/2022 at 1:00 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/Unit Manager (UM)] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for. She has dementia. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. An interview was conducted with Staff B, LPN on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/UM] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. Review of timecards revealed Staff B, LPN clocked in at 6:37 a.m. on 10/25/2022. Review of Resident #7's Medication Administration Record (MAR) revealed Staff B, LPN did not document administration of any medications or tube feeding until 10:00 a.m. on 10/25/2022. On 11/02/2022 at 10:25 a.m., a telephone interview was conducted with Staff H, CNA. She confirmed she had worked both the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift from 10/24/2022 - 10/25/2022. She confirmed she was assigned care for Resident #7 for both shifts. She stated she had been a permanent employee at the facility since June 2022 and typically worked the 3:00 p.m. - 11:00 p.m. shift. Staff H said, [Resident #7] likes to dig in her diaper. She pull her diaper off. She pulls at her feeding tube. She digs in her poop. She'll look at you, she'll smile, she screams, she cries, all communication is unintelligible. Staff H stated Resident #7 was not able to make her basic needs known or respond to basic questions. She stated Resident #7 was dependent on facility staff for everything. Staff needed to anticipate her needs, provide all levels of care, and required a mechanical lift for transfers out of bed. Staff H stated she started her shift on 10/24/2022 at about 2:45 p.m. and she did her last resident rounds on 10/25/2022 at about 4:45 a.m. She said, when I do a double like that I start my last rounds at quarter to 5 and after I do my last rounds I chart. Staff H stated she thought she clocked out around 7:30 a.m. on 10/25/2022. Staff H reported she changed the resident during both shifts and said, my last rounding and care with [Resident #7] was a little bit after 5 a.m. I changed her because she was wet and pooped so I changed her. She was in the bed, did not see a restraint at that time. Staff H said, I never saw that restraint on the resident at any time. Staff H stated she had never received any training on restraint use or abuse at any time from the facility. Staff H confirmed she was no longer employed by the facility and said, they terminated me because I wouldn't write a statement, but by law I don't have to write a statement. I answered their questions just like I'm doing with you now and told them the same things. They said because I was the last one to take care of her I was the focus. Staff H said, I feel hurt. It hurt me because they tried to blame me for something I didn't do. I'm not the only one accountable for this because I wasn't the only one that was there .also there was no CNA to relieve me .somebody told me it was after 10 a.m. going on 11 a.m. that a CNA was called in for the resident. There was a long period of time after my last contact with the resident where anything could have happened. Like the nurse [Staff J, LPN] had to give the [tube] feeding. Review of timecards revealed Staff H, CNA clocked in at 2:47 p.m. on 10/24/2022 and clocked out at 7:32 a.m. on 10/25/2022. Review of CNA task documentation in Resident #7's medical record revealed eating was charted by Staff H on 10/24/2022 at 6:00 p.m. and toileting was performed by Staff H, CNA on 10/25/2022, charting time 6:59 a.m. On 11/03/2022 at 10:37 a.m., a telephone interview was conducted with Staff J, LPN. She confirmed she worked at the facility through a nursing agency. She confirmed she worked at the facility on the 11:00 p.m. to 7:00 a.m. shift on 10/24/2022 - 10/25/2022 and was the assigned nurse for Resident #7. She stated she started her shift at 10:45 p.m. and left at either 7:25 a.m. or 7:30 a.m. on 10/25/2022. She stated when she started her shift she got report from Staff I, LPN. She stated she performed feeding tube flushes for Resident #7 around 12:00 a.m. and 2:00 a.m. and performed a bolus feeding through Resident #7's feeding tube at 5:00 a.m. in the morning on 10/25/2022. She stated Resident #7 was wearing a shirt, not a gown and said when she performed the bolus feeding, I didn't see her entire body, I only saw just from her stomach area up. Staff J stated Resident #7 was in her bed during the bolus feeding. She said, [Resident #7] had a blanket on, only saw area where the tube was, always try to expose just what I need. Staff J reported she had administered insulin to the resident in the morning on 10/25/2022 and had given the injection in the resident's left arm. She stated the insulin administration was the last care task she provided for Resident #7 during that shift. Staff J reported nothing unusual occurred with Resident #7 during her shift and stated Resident #7 was asleep during the shift and said, the three or four times I saw her, she was sleeping. Staff J stated she never saw a sheet tied across Resident #7's midsection and fastened to the bed and confirmed she never saw any restraint on Resident #7 during her shift. She said, if I had seen that I would have freed her first and then I would have questioned the CNA who had her and then would have called [Staff C, LPN, UM] or, I don't even know who the DON is. Regarding the restraint found on Resident #7, Staff J said, that is a no no, that is abuse. I learned that in school. I don't even agree with stuff like that. I was just shocked, like what, and then I was shocked because I didn't see it. Staff J said, I didn't communicate with the CNA [Staff H] much. I feel like she [Staff H] could have did more rounds especially when it came to me answering most of the lights. [Staff H] had a slight attitude, just body language when I said something to her about one of the male rooms that smelled like pee pee, but she still went and checked on them. Staff J said, I don't know who put the sheet there. I don't know why someone would other than what I said about keeping people from falling, but with that you just have to check on people. There are so many tactics you can use other than restraining people. And it's prohibited. Staff J confirmed she continued working at the facility post-incident and said, they didn't remove me from the schedule or nothing so I picked up some more days after that. Regarding education or training received from the facility she said, we don't do any training at the facility and stated she did not receive any education post-event from the facility. Review of timecards revealed Staff J, LPN clocked in at 10:45 p.m. on 10/24/2022 and clocked out at 7:15 a.m. on 10/25/2022. Review of Resident #7's Medication Administration Record (MAR) revealed a bolus tube feeding and insulin injection was administered by Staff J, LPN on 10/25/2022 at 6:00 a.m. A telephone interview was conducted with Staff I, LPN on 11/02/2022 at 9:27 a.m. He confirmed he had worked at the facility maybe two or three times through a nursing agency. He confirmed he worked at the facility on 10/24/2022 on the 3:00 p.m. to 11:00 p.m. shift and was the assigned nurse for Resident #7. He stated he gave her medications and gave her a bolus feeding through her feeding tube around 5:00 p.m. or 6:00 p.m. He stated he arrived to the unit for his shift at about 2:50 p.m. or 3:00 p.m. and rounded on Resident #7 at that time. He said, she was in the bed at time of my bolus feeding with her. He stated Resident #7 was a little antsy that day but otherwise was her normal self. He said, she's confused, very confused; she can't talk like me and you. Staff I stated he never saw any restraint on Resident #7 during his shift and said, if I would have saw something like that I would definitely untied it and reported it. He confirmed he was asked to provide a written statement and stated, in my written statement I told them everything just like I'm telling you, and also that I refused to work at a facility that tied people to the bed, and I refuse to go back there. I won't work at a facility that would do something like that. Staff I stated the DON had asked him, did two CNAs get into it during his shift and he told the DON no, but that he remembered the 11:00 p.m. to 7:00 a.m. CNA who worked a double was upset. Staff I said that CNA had been upset because the previous CNA had not completed care and had left residents wet and she was upset about working the shift, upset about working in general. Staff I said, I'm not saying she (the CNA) did it, but she definitely didn't feel like working and had an attitude. Staff I said, the lady [Resident #7] was a fall risk, I know that. She was a busy body, moved around a lot. They [the staff] didn't like that about her. If they did tie her to the bed that was probably the reason. Staff I said, the fact that happened was highly upsetting, that's totally abuse. I can't imagine someone would do something like that. I won't work in a place like that. Review of timecards revealed Staff I, LPN clocked in at 2:45 p.m. on 10/24/2022 and clocked out at 11:15 p.m. on 10/24/2022. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H was suspended pending investigation but said Staff I and Staff J were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they infor[TRUNCATED]

Based on record review, interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's Medical Director, the facility Administration failed to use its resouces effectively to lead and direct the overall operations of the facility in accordance with resident needs, regulations, and company policies related to abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, Resident #7, a cognitively and physically impaired resident who had a communication deficit and was dependent on staff for all care and services, was found by a Certified Nursing Assistant (CNA) restrained to her bed by a sheet placed across her midsection and tied to the bedframe. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA), who also served as the facility's Abuse Coordinator. Facility administration determined this was not abuse, did not fully investigate, report, protect, and take corrective action to prevent a similar occurrence. The failure of the Administration to follow CMS guidelines and to implement their abuse policies created a likelihood that placed all residents at risk of a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, or serious psychosocial harm (using the psychosocial severity guide), serious impairment or death due to ligature risk. This resulted in the findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference to F600, F609, and F610. Review of the facility job description titled, Administrator dated December 2018 revealed: Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and complany policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilites included: Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary. Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Develop an environment that allows for creative thinking, problem solving, and empowerment in the development of a facility management team. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; Morale of the staff; And ensure resident needs are being addressed. Responsible for the QA (Quality Assurance) program. Maintain a working knowledge of and confirm compliance with all governmental regulations. Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development. Consult with department managers concerning the operation of their departments to assist in eliminating\correcting problem areas, and\or improvement of services. Provide guidance and leadership throughout the survey process to ensure state and federal regulations are met and adhered to. Job Requirements included: Strong attention to detail and accuracy, excellent organizational skills with the ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Strong analytical and problem solving skills. Ability to work with minimal supervision, take initiative and make independent decisions. Ability to deal with new tasks without the benefit of written procedures. During an interview on 10/31/2022 at 3:24 p.m., the facility Administrator (NHA) confirmed that she was also the facility's designated Abuse Coordinator. Request for additional facility job descriptions for Abuse Coordinator was requested on 11/03/2022 at 3:15 p.m. The Regional Nurse Consultant (RNC) and the Regional Director of Operations (RDO) reported there was no separate description and that those responsiblities were embedded in the facility NHA job description. Review of the facility's Administrator job description revealed no specifications related to the role or duties of Abuse Coordinator for the facility. Review of the facility's Director of Nursing (DON) job description dated August 2021 revealed: Summary: to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices, and governmental regulations to maintain excellent care of all residents' needs. Essential Duties & Responsibilities included: Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and\or improve the work environment. Management duties including, but not limited to, hiring, training, and developing, coaching, and counseling, and terminating department staff, as deemed necessary. Participate in facility surveys (inspections) made by authorized governmental agencies. Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facility. Ensure attainment of staffing requirements based on current needs and State and Federal guidelines. Ensure that the risk portal Is maintained and or completed in a timely manner. Ensure the provision of appropriate departmental in-service education programs and compliance with Corporate, State and Federal guidelines. Direct the performance and delivery of nursing services and resident care services in compliance with Corporate policies and State and Federal regulations. In conjunction with the NHA, inform the state of any reportable incidents within appropriate time frames. Complete investigative analysis as required, and file reports based on state guidelines. Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations. Review Resident Incident Reports and facilitate corrective action. Comply with, support, and enforce company policies involving all safety . procedures. Review and verify that documentation procedures for nursing are met according to corporate, state, and federal guidelines. Job Requirements: Ability to communicate on all levels of organization and work well within a team environment in support of company objectives. Customer service oriented with the ability to work well under pressure. Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Strong analytical and problem solving skills. Ability to deal with new tasks, work with minimal supervision, take initiative and make independent decisions. A review of the policy titled Medical Director Responsibilities with a copyright date of 2020 and no implementation/review/or revision date revealed: Policy: The facility retains a physician designated as Medical Director, to a coordinate the medical care provided by attending physicians, and to assist with development and implementation of resident care policies. 4. The Medical Director's responsibilities include participation in: a. Administrative decisions including recommending, developing and approving facility policies related to resident care of physical, mental and psychosocial well-being; b. Issues related to the coordination of medical care identified through the facilities QA committee and other activities related to the coordination of care; c. Organizing and coordinating services provided by other professionals as they relate to resident care; d. Participate in the QA committee. Review of the facility policy titled Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of inury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprevation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facility or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 6. Physical abuse of a resident observed. 7. Psychological abuse of a resident observed. 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning. 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA reported Staff E, CNA was the first witness to observe Resident #7 in bed with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, Licensed Practical Nurse (LPN)] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the Unit Manager [Staff C, LPN/UM] performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H was suspended pending investigation but said Staff I and Staff J were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA said, there was never any indication from [Resident #7's niece] that she thought this was abuse related. The NHA stated the facility's Social Services Director (SSD) did a trauma assessment and said, and I think also a BIMS assessment. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. Review of the facility nursing staff and assignment schedule revealed Staff I, LPN was not scheduled at the facility after 10/24/2022. Staff J, LPN was scheduled and assigned care for Resident #7 on 10/26/2022 and was scheduled in the facility on 10/28/2022 and 10/29/2022. On 11/01/2022 at 1:28 p.m., a telephone interview with the facility's Medical Director confirmed the facility informed him of the restraint incident with Resident #7. The Medical Director said, I think they notified me afterwards because they didn't think it was a reportable incident. They notified me a few days later in morning meeting. The Medical Director stated the restraint was described to him as loosely tied. He said, we bantered this around, was almost like trying to make an analogy of a person in a wheelchair who was mobile and putting a laptop or safety belt around them, that would impede their mobility and be considered a restraint. But [Resident #7], I looked at her case, someone bedbound, total care, couldn't move, didn't look good but didn't impede mobility in reality. Regarding whether psychosocial impact was discussed he said, I don't think that came up, no, but that's a good point. He then stated, I think someone said her BIMS was basically zero meaning she wasn't alert and aware of her surroundings so because of that I wouldn't have been worried about psychosocial impact but if she had been alert and aware, I would have been concerned about that. The Medical Director stated he was not asked to participate in an investigation. He said, I don't know if they're done with their investigation, I know they were talking to some people, I don't know the outcome. The Medical Director stated there had been no QA process or meeting related to the incident that he was involved in and said, Our QA is coming up this Thursday so I'm sure it will come up. Review of the facility logs titled Incidents By Incident Type and Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs revealed no entries related to Resident #7. On 11/01/2022 at 1:41 p.m., during an interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. On 10/31/2022 at 1:00 p.m., Staff D, LPN confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. Staff D reported she was working on the unit for Resident #7 but was not her assigned nurse for the 7 a.m. - 3 p.m. shift. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/UM] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for. She has dementia. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 and said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. On 10/31/2022 at 11:40 a.m., Staff B, LPN revealed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B said, it was around 10:30 a.m. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and stated, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know an