**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident, staff, and family interviews, the facility failed to honor a resident's (Resident #49) right to choose their preferred method of bathing and the resident's right to refuse a shower. On 4-22-23, Resident #49 had refused her shower three times and on the third refusal Nurse #1 was informed of Resident #49's refusal to take a shower. Nurse #1 informed Nursing Assistant (NA) #1 and NA #2 that the resident had to take a shower regardless of Resident #49's refusal. Nurse #1 and 5 NAs (NA #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and stating she did not want to get out of bed and have a shower, out of the bed, into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the likelihood of suffering serious physical and psychosocial harm. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). This deficient practice was for 1 of 4 residents reviewed for choices. Immediate Jeopardy began on 4-22-23 when six staff members forced Resident #49 out of her bed to receive a shower. Immediate Jeopardy was removed as of 6-10-23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings included: Resident #49 was admitted on [DATE] with multiple diagnoses that included vascular dementia without behavioral disturbances and atrial fibrillation. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired, and documentation showed that choosing her preference for bathing was very important to Resident #49. Resident #49's activities of daily living care plan initiated on 1-4-2020 and revised on 9-20-22 revealed the resident had an activities of daily living self-care deficit. The goal for Resident #49 was to maintain current level of function with her activities of daily living. The interventions for the goal included Resident #49 required total assistance with bathing and if the resident refuses, allow a few minutes to pass and then re-attempt to get the resident to agree to a shower or bath. Provide the resident with a sponge/bed bath when a full bath or shower cannot be tolerated. There was no documentation regarding Resident #49's preferred bathing choice. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired and exhibited physical behaviors towards others 1-3 days in the 7 days look back period and had refused care 1-3 days during the 7 days look back period. Resident #49 was documented as needing physical help with two people for bathing and extensive help with two people for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDs also documented Resident #49 received an anticoagulant (medication to inhibit the clotting of blood) 7 out of 7 days during the 7 day look back period. Skin assessments conducted from 4/1/23 through 4/21/23 revealed no bruises were present on Resident #49. Review of Resident #49's medical record revealed a nursing note dated 4-23-23 at 10:37pm written by Nurse #2. The nurse documented she had been called to the resident's room by a family member (daughter) who was questioning what had happened to Resident #49's hand which had a bruise on her left hand. Nurse #2 documented that Resident #49 had told her it happened in the shower a couple of days ago. The facility's final investigation report dated 4-28-23 revealed Resident #49's daughter called the Administrator on 4-25-23 and reported the resident had been abused in the shower on Saturday (4-22-23). The documentation showed the daughter told the Administrator she visited Resident #49 on 4-23-23 and noticed a bruise on the resident's hand. The daughter informed the Administrator that Resident #49 told her staff were pinching her hand during her shower. The daughter also informed the Administrator she had spoken to the charge nurse on 4-23-23 who assessed Resident #49's hand for damage. The investigation report documented Resident #49 had a bruise on the top of her left hand. The investigation report included written statements from staff who had contact with Resident #49 on 4-22-23. Resident #49 was interviewed on 6-5-23 at 10:39am. Resident #49 confirmed she remembered when she sustained a bruise to her hand on 4-22-23. The resident commented, It stayed bruised for a long time. Resident #49 said the girl was trying to force me into the shower chair and was squeezing my hand. I told her to stop because she was hurting me, but she did not. She also stated she was fighting with the staff because she did not want to get a shower. Resident #49 discussed that she preferred to get bed baths. The resident would not discuss how she felt during the incident on 4-22-23 but instead kept stating I don't want to get anyone fired. Resident #49 discussed telling a family member (her daughter) on 4-23-23 what happened and stated she did not tell any other staff because she was concerned about the staff's jobs. She stated she had not received any other bruises since 4-22-23. Upon observation of the resident, she was observed not to have any bruising to her hands. Resident #49 was observed on 6-5-23 at 10:39am. The resident was observed to be lying in bed. Her clothes were noted to be clean, there were no odors observed, her hair was observed to flow down to the middle of her back and was clean but uncombed. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter discussed visiting the resident on 4-23-23 and noticed a bruise on the resident's hand that was black and blue in color. She stated when she asked Resident #49 what happened the resident told her staff had given her (resident) a shower yesterday (4-22-23). The daughter further discussed Resident #49 telling her she (the resident) was combative because she did not want a shower, so the resident told the daughter that staff held her hand down and pinched her hand. The daughter said she informed Nurse #2 of the bruise to Resident #49's hand and stated the nurse took a picture of the bruise and told her the staff would monitor the area. The daughter stated she never told staff to force the resident to have a shower. She explained she told staff to encourage the resident to take a shower but if the resident refused it was ok. She explained she knew the resident did not like getting a shower and preferred to have bed baths. The daughter stated on 4-23-23 during the visit that the resident told her she did not think staff liked her. NA #1's written statement dated 4-26-23 related to the incident on 4-22-23 indicated that she assisted with transferring Resident #49 from the bed to the wheelchair so she could be brought to the shower room. The statement further indicated that she did not aid with giving Resident #49 the shower. NA #1 was interviewed on 6-6-23 at 12:46pm. NA #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #1 was asked to clarify her statement and explain Resident #49's behaviors as well as staff's course of action. NA #1 stated Resident #49 was real bad to refuse showers. She discussed that she did not know if the resident's preference in bathing was written anywhere but stated she usually asked Resident #49 if she wanted a shower or bed bath. She further discussed the resident being allowed to refuse a shower but not all the time. NA #1 explained Resident #49 was allowed to refuse one shower a week but the second scheduled shower, the resident was not allowed to refuse. NA #1 explained on 4-22-23 Resident #49 refused her shower 2-3 times and after the last refusal, she informed Nurse #1 that the resident was refusing her shower. The NA stated Nurse #1 told her to get the resident up and take her to the shower anyway. She stated there were six staff in the room (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) and that it took four staff (the NA could not remember which staff) to sit Resident #49 on the edge of the bed. NA #1 explained during this time, the resident was throwing her hands around, pushing away from staff and putting her arms up guarding herself. The NA stated once Resident #49 was talked into receiving a shower, the resident was no longer combative. NA #1 explained Resident #49 would stick her right hand through the side rails and bang her hand over the bed table when she wanted something. The NA stated she worked with Resident #49 on 4-20-23 and the resident did not have a bruise on her hand and said she did not see if Resident #49 had a bruise on her left hand during the transfer on 4-22-23. Nurse #1's written statement that was undated following the incident on 4-22-23 read; I was called down to the resident's room to help them get her up for a shower. She was refusing as she always does. I told her [her son] wanted her to get a shower. She told us [her son] was not the boss of her. We (the CNAs and myself) assisted [Resident #49] to sitting on her bed, then put her on the shower chair. She was not happy getting up, but smiling and apologizing when her shower was done. During an interview with Nurse #1 on 6-6-23 at 1:17pm, Nurse #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. The nurse was asked to discuss Resident #49's behavior and explain what happened when the resident refused her showers. The nurse confirmed she was the charge nurse on 4-22-23 but stated she did not remember the incident. Nurse #1 stated if it was a shower day for Resident #49 then the resident would have been combative by flailing her hands and arms but said usually once the resident was assisted by staff into a seated position on the edge of the bed the resident would stop being combative. After reading her written statement for the 4-22-23 incident that she provided to the facility during their investigation, she stated she remembered being told Resident #49 was refusing her shower and she went to the resident's room to speak with her along with five NAs (NA #1, NA #2, NA #3, NA #4, and NA #5). Nurse #1 was unable to explain why six staff members went to Resident #49's room. The nurse stated once Resident #49 was placed in the shower chair, the resident stopped being combative. Nurse #1 explained typically if a resident refused a shower three times, the resident would be provided a bed bath but stated with Resident #49, she would sometimes be forced to get a shower because the resident's hair was long and became matted if she did not receive a shower. She explained the facility had washing caps that could be used to wash the resident's hair but stated they did not work well. She further stated the family had told staff they wanted the resident to have at least one shower a week. Review of NA #5's written statement dated 4-26-23 following the incident on 4-22-23 read; Resident #49 did not want to take her shower but me and [Nurse #1] got her to go take it. The bruise on her hand is where she puts her hand through the rail on the bed all the time. She keeps a bruise on that hand a lot from the bed rails. A telephone interview occurred with NA #5 on 6-6-23 at 3:01pm. NA #5's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #5 was asked to discuss Resident #49's behavior, what happens when the resident refused a shower, and the bruise Resident #49 sustained to her left hand. The NA confirmed she assisted with getting Resident #49 out of bed for a shower on 4-22-23. She stated she remembered the resident was combative because the resident did not want to get out of bed and take a shower. NA #5 stated, while trying to get Resident #49 into the shower chair, the resident attempted to hit one of the NAs. She stated she could not remember which one, but it was one of the NAs standing behind the resident. The NA stated there were six staff members (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) in the room and she could not remember who was standing behind the resident. NA #5 explained Resident #49 was allowed to refuse one shower a week but then the resident will be forced the next shower day. She explained if Resident #49 refused the shower, staff tried to talk her into receiving a shower. She further explained that if she was not able to be talked in to receiving her shower, the resident was forced to get up out of the bed to take a shower. The NA discussed typically residents were allowed to refuse a shower four to five times on their shower day but then the nurse on duty had to be informed of the refusal and it was up to the nurse on duty to decide if the resident needed to be forced to get up and receive a shower. She stated she could not remember if Resident had a bruise on her left hand on 4-22-23. NA #2's written statement dated 4-25-23 following the incident on 4-22-23 read; Per [NA #2] I did not help to give [Resident #49] her shower on Saturday. I did assist with getting her back into bed after the shower. She was fine with me and was not being combative. When asked about the bruise on resident's hand, [NA #2] told interviewer that [Resident #49] had that bruise before Saturday. During a telephone interview with NA #2 on 6-6-23 at 3:34pm, NA #2's provided statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #2 was asked if she assisted with Resident #49's transfer prior to the shower, resident's behavior, and what happened if Resident #49 refused a shower, as well as the bruise on Resident #49's hand. NA #2 stated she assisted in transferring Resident #49 from the bed to the shower chair on 4-22-23. NA #2 discussed Resident #49 telling the staff she did not want a shower and had been combative until she was placed in the shower chair. The NA stated she could not remember how many staff were in the room but said there were a lot of us. She was unable to explain why there were so many staff in the room. She also discussed Resident #49 never wanting to get out of bed and usually when she refused her shower a bed bath was provided. NA #2 explained she did not think the resident's preference for bathing was written anywhere but said she usually asked the resident if she wanted a bed bath or shower. The NA stated she did not know why she was being made to get a shower on 4-22-23. NA #2 stated she did not see a bruise on Resident #49's hand when transferring the resident into the shower chair. She stated she said in her written statement Resident #49 had the bruise before Saturday (4-22-23) because the resident always keeps a bruise on her hand. Review of NA #3's written statement dated 4-26-23 to the facility following the incident on 4-22-23 read; [NA #5, NA #4, NA #2, Nurse #1] and myself all assisted in getting her from the bed to the shower chair in her room. She didn't want to go at first but did fine with all of us helping her in the chair. [NA #4] and I pushed her in the shower room and began her shower and she was thanking us for bathing her and she even apologized for being an old fart (her words) and not wanting to take a shower. We dressed her and took her back to the room and she wanted to go back to bed so we assisted her in that. We hooked up her oxygen and she was good. NA #3 was interviewed by telephone on 6-6-23 at 7:12pm. NA #3's statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior. NA #3 explained Resident #49 was scheduled for a shower on 4-22-23 but the resident had been refusing. She said it took five people (Nurse #1, NA #1, NA #2, NA #4, and NA #5) plus herself to get Resident #49 out of the bed because the resident was pushing them away and not wanting to get up. NA #3 explained Resident #49's preference for bathing was not documented anywhere and said she usually just asked the resident if she wanted a bath or shower. Na #4's written statement dated 4-27-23 following the incident on 4-22-23 read; On Saturday we asked [Resident #49] if she was ready for a shower and she didn't want to get out of bed but then finally said she was ready but still gave us a hard time to get out of bed so I went to ask the other CNAs [NA #5, NA #1, NA #3] if they could help because she was screaming at me, at that time [NA #5] went and got the charge nurse [Nurse #1] to help. They got [Resident #49] up put of the bed and into the shower chair and we wheeled her down to the shower room and me and [NA # 3] gave her a shower. She was fine in the shower and kept saying how sorry she was for giving us a hard time getting out of bed. She was calm and gentle while in the shower. We washed and dressed her and got her back in the room and she got her toenails cut by [NA #2] and [NA #2] had helped me get her in the bed and she was fine and helped us and said thank you. An interview with NA #4 occurred on 6-7-23 at 9:01am. NA #4's written statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior prior to the shower. NA #4 stated on 4-22-23 she asked Resident #49 if she wanted a shower and said the resident was agreeable to receiving a shower. She stated she left the resident's room to ask for more help because she was not familiar with the resident and could not transfer the resident on her own. NA #4 was unable explain why her written statement was different. She stated during the transfer Resident #49 was pushing against them and fighting. NA #4 explained she never heard the resident say she did not want a shower. The previous Social Worker (SW) was interviewed by telephone on 6-6-23 at 4:44pm. The previous SW stated she had conducted the investigation for the abuse allegation towards Resident #49 on 4-25-23 after the Administrator received a call from Resident #49's daughter, saying the resident had been roughed up by staff in the shower on 4-22-23. She stated she first questioned staff and then questioned Resident #49 about the incident on 4-22-23. She stated the staff were consistent in their statements that Resident #49 was combative getting into the shower chair because the resident did not want a shower. The previous SW stated she had not questioned staff on their response when the resident was refusing her shower or when the resident had been combative. She explained once Resident #49 was refusing her shower and had become combative, the staff should have walked away instead of forcing her into the shower. Resident #49's son who was the resident's Power of Attorney (POA), was interviewed by telephone on 6-7-23 at 9:30am. The son discussed Resident #49 being difficult at times and being strong willed but stated he never told staff to force the resident to get a shower. The son explained he knew the resident did not like showers and preferred to stay in the bed to receive bed baths. He stated he had spoken with staff to encourage Resident #49 to take a shower but said he told the staff if the resident refused to let her refuse. During an interview with NA #7 on 6-7-23 at 2:06pm, she stated resident preferences for bathing were not documented anywhere. NA #7 discussed when she was hired at the facility a few months ago, she was informed by staff (unable to recall who) residents could not just receive bed baths. NA #7 explained she asked the residents if they would like a shower or bed bath. She stated if a resident refused their shower three times, she informed the nurse and the nurse spoke with the resident. The NA stated she never felt like she was forcing a resident to take a shower. The Administrator was interviewed on 6-7-23 at 3:01pm. He stated, forcing a resident was abusive and if he had known he would have stopped it from happening. The Administrator was notified of the Immediate Jeopardy on 6-7-23 at 3:01pm. The facility provided the following Credible Allegation of Immediate Jeopardy (IJ) removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. o This deficient practice at tag F561 impacts Resident #49. o This deficient practice at tag F561 could potentially impact all residents. o During the admissions process, the admitting nurse asks about bathing preferences which is acknowledged and incorporated in their plan of care. o All interviewable residents will be interviewed by 11:59 PM on 06/09/2023 to ensure that their bathing wishes are being followed. The interviews will be conducted by the Administrator, Director of Nursing (DON), or trained designee. There have been no complaints or concerns voiced to date of their bathing schedule. To ensure that there are no complaints or concerns, the facility (Director of Nursing or Administrator or trained designee) notified the responsible parties of non-interviewable residents via phone messaging system to contact the Administrator or Director of Nursing if they have any concerns about their loved ones' shower or bathing schedules. This also included a survey to choose method of bathing. This was completed at 9:24 AM on 6/9/2023. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. o The Chief Executive Operator (CEO), Administrator, Director of Nursing (DON) or trained designee will educate 100% of all staff regarding Tag F561 by 12:00 PM on 06/09/2023, or the staff will be removed from the schedule and not allowed to work until they have been educated. This includes contract and agency staff members. The educate will include: o Residents' rights policy and procedure. o Allowing the resident to choose bathing options, including bed baths, showers, tub, and refusal all together. o How to offer the resident options on bathing. o Understanding that the resident has the right to decline all bathing. o Understanding that forcing care is abuse and can lead to harm to the patient. o Staff understanding the methods of offering bathing alternatives (examples include shower, bed baths, sink baths, bathtubs, and refusing bathing) to meet the residents' needs. o Reporting refusal of care to the charge nurse so the nurse can take extra measures to have alternative means (examples: psychiatric care referrals, notifying families for involvement, notifying physician for input on care). o 100% of staff will be educated by 12:00 PM on Friday, June 9th, 2023, or they will be removed from the schedule. Alleged date of IJ removal: June 10, 2023 On 6-12-23, the facility's plan for Immediate Jeopardy removal effective 6-10-23 was validated by the following: documentation and interviews with residents and staff. Review of the in-service sign-in sheets revealed all staff and all departments received education which included residents' right to refuse care and how to manage residents who refused care. Residents interviewed revealed all residents reported they had not been forced to do anything they did not wish to do or have care provided against their will. The staff interviewed all stated residents had the right to choose and/or refuse care and should not be forced against their will. The facility's Immediate Jeopardy removal date of 6-10-23 was confirmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, family and resident interviews, the facility failed to protect Resident #49's right to be free from physical and emotional abuse for one of two sampled residents reviewed for abuse. On 4-22-23 Resident #49 had refused a shower three times and on the third refusal, six staff members (Nurse #1, Nursing Assistant (NA) #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and pushing staff away, out of bed and into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the high likelihood of suffering other serious physical and psychosocial harm. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). Immediate Jeopardy began on Saturday 4-22-23 when six staff members forced Resident #49 out of her bed to receive a shower with the resident sustaining a bruise to her hand and feeling that staff did not like her. Immediate Jeopardy was removed as of 6-10-23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings included: Resident #49 was admitted on [DATE] with multiple diagnoses that included vascular dementia without behavioral disturbances, atrial fibrillation and chronic respiratory failure. Physician order dated 11-24-20 revealed Resident #49 was to receive Eliquis (medication to prevent blood clots) 5 milligrams (mg) twice a day. Resident #49's activities of daily living care plan initiated on 1-4-2020 and revised on 9-20-22 revealed the resident had an activities of daily living self-care deficit. The goal for Resident #49 was to maintain current level of function with her activities of daily living. The interventions for the goal included Resident #49 required total assistance with bathing and if the resident refuses, allow a few minutes to pass and then re-attempt to get the resident to agree to a shower or bath. Provide the resident with a sponge/bed bath when a full bath or shower cannot be tolerated. There was no documentation regarding Resident #49's preferred bathing choice. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired and exhibited physical behaviors towards others 1-3 days in the 7 days look back period and had refused care 1-3 days during the 7 days look back period. Resident #49 was documented as needing physical help with two people for bathing and extensive help with two people for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS also documented Resident #49 received an anticoagulant (medication to inhibit the clotting of blood) 7 out of 7 days during the 7 day look back period. Skin assessments conducted from 4/1/23 through 4/21/23 revealed no bruises were present on Resident #49. Review of Resident #49's medical record revealed a nursing note dated 4-23-23 at 10:37pm written by Nurse #2. The nurse documented she had been called to the resident's room by a family member (daughter) who was questioning what had happened to Resident #49's hand which had a bruise on her left hand. Nurse #2 documented that Resident #49 had told her it happened in the shower a couple of days ago. The initial investigative report completed by the facility's previous Social Worker (SW) dated 4-25-23 revealed the facility had received a phone call from Resident #49's daughter who told the facility the resident had been abused in the shower on Saturday (4-22-23). According to the report the daughter informed the facility that Resident #49 had told her staff were pinching her hand during her shower. The previous SW documented per the nursing assessment Resident #49 was not in any acute pain from the bruising and the resident did not report any mental anguish from the incident. The facility's final investigation report dated 4-28-23 revealed Resident #49's daughter had called the Administrator on 4-25-23 and reported the resident had been abused in the shower on Saturday (4-22-23). The documentation showed the daughter told the Administrator she had visited Resident #49 on 4-23-23 and noticed a bruise on the resident's hand. The daughter informed the Administrator that Resident #49 had told her staff were pinching her hand during her shower. The daughter also informed the Administrator she had spoken to the charge nurse on 4-23-23 who assessed Resident #49's hand for damage. The investigation report documented Resident #49 had a bruise on the top of her left hand. The investigation report included written statements from staff who had contact with Resident #49 on 4-22-23. Resident #49 was interviewed on 6-5-23 at 10:39am. Resident #49 confirmed she remembered when she sustained a bruise to her hand on 4-22-23. The resident commented, It stayed bruised for a long time. Resident #49 said the girl was trying to force me into the shower chair and was squeezing my hand. I told her to stop because she was hurting me, but she did not. She also stated she was fighting with the staff because she did not want to get a shower. Resident #49 discussed that she preferred to get bed baths. The resident would not discuss how she felt during the incident on 4-22-23 but instead kept stating I don't want to get anyone fired. Resident #49 discussed telling a family member (her daughter) on 4-23-23 what had happened and stated she did not tell any other staff because she was concerned about the staff's jobs. She stated she had not received any other bruises since 4-22-23. Upon observation of the resident, she was observed not to have any bruising to her hands. Resident #49 was observed on 6-5-23 at 10:39am. The resident was observed to be lying in bed. Her clothes were noted to be clean, there were no odors observed, her hair was observed to flow down to the middle of her back and was clean but uncombed. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter discussed visiting the resident on 4-23-23 and noticed a bruise on the resident's hand that was black and blue in color. She stated when she asked Resident #49 what had happened the resident told her staff had given her (resident) a shower yesterday (4-22-23). The daughter further discussed Resident #49 telling her she (the resident) was combative because she did not want a shower, so the resident told the daughter that staff had held her hand down and pinched her hand. The daughter said she informed Nurse #2 of the bruise to Resident #49's hand and stated the nurse took a picture of the bruise and told her the staff would monitor the area. The daughter stated she had never told staff to force the resident to have a shower. She explained she told staff to encourage the resident to take a shower but if the resident refused it was ok. She explained she knew the resident did not like getting a shower and preferred to have bed baths. The daughter stated on 4-23-23 during the visit that the resident told her she did not think staff liked her. NA #1's written statement dated 4-26-23 related to the incident on 4-22-23 indicated that she assisted with transferring Resident #49 from the bed to the wheelchair so she could be brought to the shower room. The statement further indicated that she did not aid with giving Resident #49 the shower. NA #1 was interviewed on 6-6-23 at 12:46pm. NA #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #1 was asked to clarify her statement and explain Resident #49's behaviors as well as staff's course of action. NA #1 stated Resident #49 was real bad to refuse showers. She discussed she did not know if the resident's preference in bathing was written anywhere but stated she would usually ask Resident #49 if she wanted a shower or bed bath. She further discussed the resident being allowed to refuse a shower but not all the time. NA #1 explained Resident #49 was allowed to refuse one shower a week but the second scheduled shower, the resident was not allowed to refuse. NA #1 explained on 4-22-23 Resident #49 had refused her shower 2-3 times and after the last refusal, she had informed Nurse #1 that the resident was refusing her shower. The NA stated Nurse #1 told her to get the resident up and take her to the shower anyway. She stated there were six staff in the room (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) and that it took four staff (the NA could not remember which staff) to sit Resident #49 on the edge of the bed. NA #1 explained during this time, the resident was throwing her hands around, pushing away from staff and putting her arms up guarding herself. The NA stated once Resident #49 was talked into receiving a shower, the resident was no longer combative. NA #1 explained Resident #49 would stick her right hand through the side rails and bang her hand over the bed table when she wanted something. NA #1 stated when the resident was combative, she would try to speak with the resident to calm her or she would inform the nurse on duty. The NA stated she did not see if Resident #49 had a bruise on her left hand during the transfer on 4-22-23. Nurse #1's written statement that was undated following the incident on 4-22-23 read; I was called down to the resident's room to help them get her up for a shower. She was refusing as she always does. I told her [her son] wanted her to get a shower. She told us [her son] was not the boss of her. We (the CNAs and myself) assisted [Resident #49] to sitting on her bed, then put her on the shower chair. She was not happy getting up, but smiling and apologizing when her shower was done. During an interview with Nurse #1 on 6-6-23 at 1:17pm, Nurse #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. The nurse was asked to discuss Resident #49's behavior and explain what happened when the resident refused her showers. The nurse confirmed she was the charge nurse on 4-22-23 but stated she did not remember the incident. Nurse #1 stated if it was a shower day for Resident #49 then the resident would have been combative by flailing her hands and arms but said usually once the resident was assisted by staff into a seated position on the edge of the bed the resident would stop being combative. After reading her written statement for the 4-22-23 incident that she provided to the facility during their investigation, she stated she remembered being told Resident #49 was refusing her shower and she went to the resident's room to speak with her along with five NAs (NA #1, NA #2, NA #3, NA #4, and NA #5). Nurse #1 was unable to explain why six staff members went to Resident #49's room. The nurse stated once Resident #49 was placed in the shower chair, the resident stopped being combative. Nurse #1 explained typically if a resident refused a shower three times, the resident would be provided a bed bath but stated with Resident #49, she would sometimes be forced to get a shower because the resident's hair was long and became matted if she did not receive a shower. She explained the facility had washing caps that could be used to wash the resident's hair but stated they did not work well. She further stated the family had told staff they wanted the resident to have at least one shower a week. Review of NA #5's written statement dated 4-26-23 following the incident on 4-22-23 read; Resident #49 did not want to take her shower but me and [Nurse #1] got her to go take it. The bruise on her hand is where she puts her hand through the rail on the bed all the time. She keeps a bruise on that hand a lot from the bed rails. A telephone interview occurred with NA #5 on 6-6-23 at 3:01pm. NA #5's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #5 was asked to discuss Resident #49's behavior, what happens when the resident refused a shower, and the bruise Resident #49 sustained to her left hand. The NA confirmed she assisted with getting Resident #49 out of bed for a shower on 4-22-23. She stated she remembered the resident was combative because the resident did not want to get out of bed and take a shower. NA #5 stated, while trying to get Resident #49 into the shower chair, the resident attempted to hit one of the NAs. She stated she could not remember which one, but it was one of the NAs standing behind the resident. The NA stated there were six staff members (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) in the room and she could not remember who was standing behind the resident. NA #5 explained Resident #49 was allowed to refuse one shower a week but then the resident will be forced the next shower day. She explained if Resident #49 refused the shower, staff tried to talk her into receiving a shower. She further explained that if she was not able to be talked in to receiving her shower, the resident was forced to get up out of the bed to take a shower. The NA discussed typically residents were allowed to refuse a shower four to five times on their shower day but then the nurse on duty had to be informed of the refusal and it was up to the nurse on duty to decide if the resident needed to be forced to get up and receive a shower. She stated she could not remember if Resident had a bruise on her left hand on 4-22-23. NA #2's written statement dated 4-25-23 following the incident on 4-22-23 read; Per [NA #2] I did not help to give [Resident #49] her shower on Saturday. I did assist with getting her back into bed after the shower. She was fine with me and was not being combative. When asked about the bruise on resident's hand, [NA #2] told interviewer that [Resident #49] had that bruise before Saturday. During a telephone interview with NA #2 on 6-6-23 at 3:34pm, NA #2's provided statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #2 was asked if she assisted with Resident #49's transfer prior to the shower, resident's behavior, and what happened if Resident #49 refused a shower, as well as the bruise on Resident #49's hand. NA #2 stated she assisted in transferring Resident #49 from the bed to the shower chair on 4-22-23. NA #2 discussed Resident #49 telling the staff she did not want a shower and had been combative until she was placed in the shower chair. The NA stated she could not remember how many staff were in the room but said there were a lot of us. She was unable to explain why there were so many staff in the room. She also discussed Resident #49 never wanting to get out of bed and usually when she refused her shower a bed bath was provided. NA #2 explained she did not think the resident's preference for bathing was written anywhere but said she usually asked the resident if she wanted a bed bath or shower. The NA stated she did not know why she was being made to get a shower on 4-22-23. NA #2 stated she did not see a bruise on Resident #49's hand when transferring the resident into the shower chair. She stated she said in her written statement Resident #49 had the bruise before Saturday (4-22-23) because the resident always keeps a bruise on her hand. Review of NA #3's written statement dated 4-26-23 to the facility following the incident on 4-22-23 read; [NA #5, NA #4, NA #2, Nurse #1] and myself all assisted in getting her from the bed to the shower chair in her room. She didn't want to go at first but did fine with all of us helping her in the chair. [NA #4] and I pushed her in the shower room and began her shower and she was thanking us for bathing her and she even apologized for being an old fart (her words) and not wanting to take a shower. We dressed her and took her back to the room and she wanted to go back to bed so we assisted her in that. We hooked up her oxygen and she was good. NA #3 was interviewed by telephone on 6-6-23 at 7:12pm. NA #3's statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior. NA #3 explained Resident #49 was scheduled for a shower on 4-22-23 but the resident had been refusing. She said it took five people (Nurse #1, NA #1, NA #2, NA #4, and NA #5) plus herself to get Resident #49 out of the bed because the resident was pushing them away and not wanting to get up. Na #4's written statement dated 4-27-23 following the incident on 4-22-23 read; On Saturday we asked [Resident #49] if she was ready for a shower and she didn't want to get out of bed but then finally said she was ready but still gave us a hard time to get out of bed so I went to ask the other CNAs [NA #5, NA #1, NA #3] if they could help because she was screaming at me, at that time [NA #5] went and got the charge nurse [Nurse #1] to help. They got [Resident #49] up put of the bed and into the shower chair and we wheeled her down to the shower room and me and [NA # 3] gave her a shower. She was fine in the shower and kept saying how sorry she was for giving us a hard time getting out of bed. She was calm and gentle while in the shower. We washed and dressed her and got her back in the room and she got her toenails cut by [NA #2] and [NA #2] had helped me get her in the bed and she was fine and helped us and said thank you. An interview with NA #4 occurred on 6-7-23 at 9:01am. Na #4's written statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior prior to the shower. NA #4 stated on 4-22-23 she had asked Resident #49 if she wanted a shower and said the resident was agreeable to receiving a shower. She stated she left the resident's room to ask for more help because she was not familiar with the resident and could not transfer the resident on her own. NA #4 was unable explain why her written statement was different. She stated during the transfer Resident #49 was pushing against them and fighting. NA #4 explained she never heard the resident say she did not want a shower. Nurse #2 was interviewed by telephone on 6-6-23 at 2:17pm. The nurse explained on 4-23-23, Resident #49's family member had asked her how the resident received a bruise to her left hand. Nurse #2 stated she assessed the area and saw the resident had a bruise to her left hand and thought Resident #49 might have had blood work completed. The nurse stated once she saw there was no documentation of blood work being completed, she informed the family member staff would monitor the site and stated she took a picture of the bruise. Nurse #2 discussed being told by the family member, that Resident #49 had told her the bruise had occurred with staff while she was in the shower. The previous Social Worker (SW) was interviewed by telephone on 6-6-23 at 4:44pm. The previous SW stated she had conducted the investigation for the abuse allegation towards Resident #49 on 4-25-23 after the Administrator had received a call from Resident #49's daughter, saying the resident had been roughed up by staff in the shower on 4-22-23. She stated she first questioned staff and then questioned Resident #49 about the incident on 4-22-23. She stated the staff were consistent in their statements that Resident #49 was combative getting into the shower chair because the resident did not want a shower. The previous SW stated she had not questioned staff on their response when the resident was refusing her shower or when the resident had been combative. She explained once Resident #49 was refusing her shower and had become combative, the staff should have walked away instead of forcing her into the shower. The Administrator was interviewed on 6-7-23 at 3:01pm. He stated, forcing a resident was abusive and if he had known he would have stopped it from happening. The Administrator was notified of Immediate Jeopardy on 6-7-23 at 3:01pm. The facility provided the following Credible Allegation of immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. o This deficient practice cited at tag F600 had a high likelihood of resulting in serious physical and psychosocial harm for Resident #49. o Initial Report was filed at 3:43 PM on 04/25/2023. o Adult Protective Services (APS) notified on 4/26/2023. o Date of final investigation submission was 4/28/2023 at 2:24 PM. o Police Notified 5/4/2023. o This deficient practice at tag F600 could potentially impact all residents. o Resident #49 has shown no signs or symptoms of psychosocial harm as of 6/8/2023. No signs or symptoms of psychosocial harm were documented from the below assessments: o Resident #49 was visited by Administrator on 4/25/2023. o Resident #49 was visited by Licensed Clinical Social Worker (LCSW) on 4/25/2023. o Resident #49 was assessed by Registered Nurse (RN) on 5/11/23. o Resident #49 was visited by LCSW on 5/12/2023. o Resident #49 was visited by Psychiatric NP on 5/12/2023. o Resident #49 was assessed by Licensed Practical Nurse (LPN) on 5/13/23. o Resident #49 was visited by Palliative Care Nurse NP on 5/24/23. o Resident #49 was visited by LCSW on 5/26/2023. o Resident #49 was visited by Nurse Practitioner (NP) 5/31/2023. o All residents with a Brief Interview for Mental Status (BIMs) below 8 (who had a shower on the allegation date) had skin assessments completed with no relevant findings during the initial investigation. This was completed by RN Charge Nurse on 4/26/2023. o All residents with a BIMs 8 or above (who had a shower on the allegation date) were interviewed and there were no relevant findings during the initial investigation. The Social Services Director interviewed the residents on 4/26/2023. o The facility will interview all residents with a BIMs of 8 or above regarding Abuse by 11:59 PM on 06/09/2023. The interviews will be conducted by the Administrator or Director of Nursing (DON) or trained designee. o The facility will conduct skin assessments on all residents with a BIMs below 8 by 11:59 PM on 06/09/2023. The Director of Nursing or other licensed nurses as designated by the DON will be responsible for the skin assessments. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. o The Chief Executive Operator (CEO), Administrator, Director of Nursing (DON) or trained designee will educate 100% of staff regarding Tag F600 by 12:00 PM on 06/09/2023, or the staff will be removed from the schedule and not allowed to work until they have been educated. This includes contract and agency staff members. The educate will include: o Understanding and identifying the types of abuse. o The reasonable person concept in regard to abuse. o How to manage and address residents who refuse care. o How to address and handle residents with combative behaviors o Understanding that forcing care is abuse and can result in serious injury. o Understanding that the resident has a right to be free from abuse. o 100% of staff will be educated by 12:00 PM on Friday, June 9th, 2023, or they will be removed from the schedule. Alleged date of IJ removal: June 10, 2023 On 6-12-23, the facility's plan for Immediate Jeopardy removal effective 6-10-23 was validated by the following: documentation and interviews with the residents and staff. Review of the in-service sign in sheets revealed all staff and all departments received education which included understanding and identifying the various types of abuse, residents' right to be free from abuse, and how/who/when to report concerns of abuse. Review of the facility documentation revealed skin audits were completed 06/09/23 on all cognitively impaired residents with no concerns or new skin abnormalities identified and staff interviews completed 06/09/23 with all alert and oriented residents revealed no concerns of abuse. Residents interviewed revealed no concerns of abuse. Residents all reported they felt safe residing in the facility. Staff interviewed from various departments and shifts all confirmed they received in-service education and were able to verbalize the types of abuse, what constituted abuse, and when and who to report any concerns. The facility's Immediate Jeopardy removal date of 6-10-23 was confirmed.