James L West Center for Dementia Care
Non profit - Corporation
112 Beds
Independent
Data: November 2025
7 Immediate Jeopardy citations
Trust Grade
0/100
#743 of 1168 in TX
Photo by James L. West Center for Dementia Care
Photo by Ravi Koirala
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Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
James L West Center for Dementia Care has a Trust Grade of F, indicating significant concerns about the facility's care standards. It ranks #743 out of 1168 in Texas, placing it in the bottom half of nursing homes in the state, and #44 out of 69 in Tarrant County, meaning there are only a few better options locally. While the facility's trend is improving, with a reduction in issues from 12 to 5 over the last year, the staffing rating is notable at 4 out of 5 stars, with a turnover rate of 46%, which is below the state average. However, $71,321 in fines raises concerns about repeated compliance problems, and the facility has less RN coverage than 86% of Texas facilities, which could affect the quality of care. Specific incidents raised during inspections include a CNA physically pinning a resident's arms to the bed and using weight to force compliance, which indicates serious issues with resident safety and dignity.
- Trust Score
- F
- In Texas
- #743/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $71,321 in fines. Higher than 99% of Texas facilities. Major compliance failures.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 37%
Review needed
12 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 5 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Texas average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 46%
Near Texas avg (46%)
Higher turnover may affect care consistency
Federal Fines: $71,321
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 18 deficiencies on record
7 life-threatening 1 actual harm
Jun 2025
5 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 5 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 5 residents (Resident #30 and Resident #79) reviewed for abuse.
The facility failed to ensure Resident #79 was free from abuse on 10/07/24. Resident #30, who had a diagnosis of dementia and was relocated from a private room to a semi-private room with roommate Resident #79. The early morning of 10/07/24, Resident #30 woke up and was startled when seeing roommate Resident #79 in the room, which resulted in Resident #30 physically assaulting Resident #79 placing the resident at risk for fear.
The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 10/07/24 and ended on 10/11/24. The facility had corrected the noncompliance before the investigation began.
This failure could place residents at risk of accidents, injuries, and hospitalization.
Findings included:
Record review of Resident #30's admission Record dated 06/12/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #30's quarterly MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, unspecified severity, with agitation, depression, psychotic disorder, and essential hypertension (high blood pressure). Resident #30's BIMS score was 02 indicating severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #30 had physical and verbal behavioral symptoms.
Record review of Resident #30's Care Plan revised 04/10/25 reflected Focus: [Resident #30] has potential to be physically aggressive r/t Dementia, Poor impulse control. He will hit, kick, bite, and punch at the staff at times. Goal: The resident will demonstrate effective coping skills through the review date. Interventions: Notify MD and or [Name] Psych Services for behavior management and medication review. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later.
Record review of Resident #79's admission Record dated 06/12/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #79's quarterly MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and psychotic disorder. Resident #79's BIMS score was 00 indicating severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #79 had physical and verbal behavioral symptoms.
Record review of Resident #79's Care Plan, undated, reflected Focus: [I] have the potential to become aggressive with other residents due to my dementia . Goal: [I] will have no or fewer episodes of aggression toward self or others during through this look back period. Interventions: Redirect and provide a quiet area away from others. Remove resident and make sure Resident is safe from self and others when resident becomes agitated.
Record review of the Provider Investigation Report dated 10/16/24 reflected, Nursing staff alert by resident calling out for help. Upon entering the room staff found Resident #2 [Resident #30] in Resident #1 [Resident #79] bed hitting and biting him. Residents were immediately separated. Head to toe assessment completed. First aid administered. Resident #2 [Resident #30] relocated to another room. Immediate notification by physician, responsible party, and VA. Increase supervision by nursing staff. Resident #1 [Resident #79] was able to return to sleep after incident without noted distress. Resident #2 [Resident #30] was relocated back to previous private room and was able to return to sleep without further distress. Resident #2 [Resident #30] has been in a private room since admission to the facility and was recently moved to a semi-private per resident's family request. It is believed Resident #2 [Resident #30] woke up and thought an intruder was in his room and reacted. Staff educated on Abuse and Neglect, Resident to Resident altercation, safe surveys completed.
Record review of Resident #30's progress noted dated 10/07/24 at 01:30 AM by LVN C reflected, This nurse and the CNA's heard a loud shout for help at around 12:30am and found resident on the bed with his roommate. Resident was hitting and biting his roommate. We immediately got resident off roommate's bed. HTT assessment was done on resident. No injuries noted on this resident. Resident was taken to his former room to sleep to avoid any further aggression towards his roommate. MD notified.
Record review of Resident #79's progress notes dated 10/07/25 at 01:30 AM by LVN C reflected, This nurse and the CNA's heard a loud shout for help at around 12:30am and found residents' roommate on the bed with him. Resident roommate was hitting and biting him. We immediately got [resident roommate's roommate off this residents' bed]. Resident stated that his roommate got off his bed, came onto him while he was sleeping and started punching, pulling on his hairs, beard and biting him. He then started shouting for help. Residents' HTT assessment was done. Skin tears and scratches noted on his hands in 4 places and bite marks on arm and shoulder. Residents' roommate was taken to another room to sleep to avoid any further aggressions. MD notified.
Observation and interview on 06/10/25 at 9:38 AM, revealed Resident #79 was in the dining area. Resident #79 stated he was doing well; and the resident was not a good historian. Resident #79 unable to recall the incident.
Observation and interview on 06/10/25 at 10:46 AM, revealed Resident #30 was in the dining area watching television. Resident #30 stated he was doing well; and the resident was not a good historian. Resident #30 was unable to recall incident.
Interview on 06/10/25 at 7:36 PM, CNA B revealed she was the CNA assigned to Resident #30 and Resident #79 when they had an altercation. She stated during the night she heard yelling coming from Resident #30's and Resident #79's room. She stated she entered the room and observed both residents fighting. She stated she called for help and CNA D and LVN C came in to assist. She stated Resident #30 had got up from his bed, went over to Resident #79's bed and was trying to push him off the bed. She stated she could not recall much of the incident but Resident #30 bit Resident #79 on the arm and scratched him. She stated no major injuries were noted. She stated she was not sure why but Resident #30 was in a private room and was changed to a semi-private room with Resident #79. She stated Resident #30 was moved back to his previous private room that night. She stated Resident #30 and Resident #79 were roommates for about day. CNA B stated Resident #30 was known to have agitation behaviors but not physical behaviors towards other residents.
Interview on 06/10/25 at 8:18 PM, LVN D stated she was the nurse assigned to Resident #30 and Resident #79 when they had the altercation. She stated Resident #30 had a private room and was moved to a semi-private room with Resident #79. She stated she was called to the room by one of the CNAs, there was yelling coming out of the room. She stated Resident #30 had gotten up to use the restroom but was confused when he saw another person in the room and got startled. She stated Resident #30 was trying to push Resident #79 out of the bed. She stated they intervened and separated both residents. LVN D stated Resident #30 was moved to his previous private room. She stated Resident #79's injuries were superficial, he had small scratches and a small bite to the arm; no blood or broken skin. She stated it was the first altercation Resident #30 had with another resident. She stated it was the first night they were roommates.
Interview on 06/11/25 at 6:52 AM, CNA D revealed she worked the night Resident #30 and Resident #79 got into an altercation. She stated she was called to the room to assist. She stated Resident #30 was confused and woke up in the middle of the night and was startled when he observed another person in his room. She stated prior to the altercation during rounds Resident #30 was observed in bed sleeping. She stated Resident #30 was not used to having someone else in the room and was not used to the change. She stated the altercation happened on Resident #79's bed. She stated Resident #30 got up to probably use the restroom and thought Resident #79 was on his bed. She stated Resident #79 had scratches and was bit on the arm. She stated she believed it was the first night as roommates. CNA D stated Resident #30 was not known to have behaviors towards other residents.
Interview on 06/12/25 at 1:36 PM, the DON revealed Resident #30 was in a private room since admission; however, the family requested for Resident #30 to be moved to a semiprivate room due to finances. She stated Resident #30 was moved to Resident #79's room. She stated Resident #30 and Resident #79 were roommates for a day or two. She stated Resident #30 got up from his bed and got confused when he saw another resident in his room. She stated Resident #30 thought Resident #79 was a stranger and started to hit resident. She stated Resident #79 began screaming, staff entered the room and intervened. She stated Resident #79 sustained superficial scratches and a bite mark. She stated it did not break the skin, it was superficial, it was only the imprint. She stated Resident #79 did not require hospitalization; they obtained a physician's order for ointment to be applied on the bite mark. She stated within a week Resident #79's injuries healed. She stated the interventions they put in place were Resident #30 was moved back to a private room, frequent monitoring, and staff were all in-serviced on abuse and neglect, and resident to resident altercations. She stated that was the first incident that occurred with Resident #30 being physical with another resident. She stated Resident #30 did not exhibited any behaviors prior to the incident. She stated they were not required to complete any assessments prior to moving a resident to another room.
Interview on 06/12/25 at 3:32 PM, the Administrator revealed she was made aware of the incident between Resident #30 and Resident #79; however, she was out for a week when the incident occurred. She stated she was notified by the DON of the incident. She stated her expectations when an altercation occurred was the staff should intervene, separate the residents, make sure residents were safe, assess for any injuries s and find out what triggered the altercation. She stated in the incident between Resident #30 and Resident #79, Resident #30 was moved from a private room to a semiprivate room with Resident #79. She stated Resident #30 was confused seeing another resident in his room. She stated Resident #30 was moved back to a private room. She stated Resident #30 never exhibited any aggressive behaviors towards other residents. She stated Resident #30's family wanted to move Resident #30 to a semiprivate room due to cost reduction. She stated she was not sure if a conversation was done with the family regarding the potential risk of moving the resident. She stated if Resident #30 had exhibited any behaviors they would have not recommended the resident to be placed with a roommate. She stated the interventions they put in place were Resident #30 was moved back to a private room, frequent monitoring, and staff were all in-serviced on abuse and neglect, and resident to resident altercations. She stated the family should be informed of any potential adverse effects may occur and potential of residents not getting along. She stated staff should supervise and monitor how the residents interact/behave due to room change. She stated they went over the monitoring during morning meetings on how the residents adjusted to the change. She stated there could be risks involved when moving a resident to another room, could cause an adverse effect on the resident.
Record review of the facility's current, undated Identifying Types of Abuse policy reflected the following:
As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.
1. Abuse of any kind against residents is strictly prohibited.
.
5. Abuse toward a resident can occur as:
a. resident-to-resident abuse.
Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:
Record review of Resident #30's Skin assessment and SBAR completed on 10/07/24, revealed no concerns noted.
Record review of Resident #30's census report, revealed Resident #30 was moved to a private room on 10/07/24.
Record review of Resident #79's Skin assessment, Change in Condition Evaluation and SBAR completed on 10/07/24. Skin assessment reflected Resident #79 sustained a skin tear on the right forearm, left outer elbow, left forearm, and bruising to the left forearm.
Record review of Safe Surveys were completed on 10/11/25 with eleven residents and revealed no issues noted.
Record review of facility In-Service Training dated 10/10/24 and 10/11/25, reflected nursing staff from 7:00 AM-7:00 PM and 7:00 PM-7:00 AM were in-serviced on Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. It may also include depriving the resident of goods and services necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse can be physical, verbal, sexual, financial, emotional and neglect . If abuse is suspected, ensure resident is safe and report the allegations. The abuse coordinator is [Administrator] [phone number] and she needs to be contacted immediately if any abuse is suspected. If there is a resident-to-resident altercation, provide safety of the resident, provide one on one if needed, refer to for evaluation as needed, and ensure that the residents are separated from one another. If the resident is combative, make sure they are safe, remove the other residents, and if needed send the resident out for further interventions with psych services.
Interviews on 06/10/25 from 1:21 PM through 06/12/25 to 3:45 PM with CNA B, LVN C, CNA D, CNA H, CNA I, CNA J, LVN K, CNA L, CNA M, RN N, CNA O, CNA P, LVN Q, CNA R, LVN A, ADON S and ADON T revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident to resident altercations. Staff monitoring behaviors, redirecting, provide activities and round checking. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated they would intervene if witness a resident-to-resident altercation, separate, ensure safe, and assess residents. Staff revealed they would report any abuse and neglect concerns to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for two of five residents (Residents #22 and #54) completed and accurate records.
1. The facility failed to ensure Resident #22's ordered Buspirone medication included an indication for use in his physician's orders.
2. The facility failed to ensure Resident #54's ordered Cymbalta medication included an indication for use in her physician's orders.
The facility failures could place residents at risk of having inaccurate medical records.
Findings included:
1. Record review of Resident #22's admission Record, dated 06/12/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #22's Annual MDS Assessment, dated 04/06/25, reflected he had a BIMS score of 06, indicating moderate cognitive impairment. His active diagnoses included non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities), anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, or dread that interferes with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event). His MDS also indicated he received antianxiety medications.
Record review of Resident #22's Order Summary Report, dated 06/12/25, reflected the following:
busPIRone [sic] HCI Oral Tablet 7.5 MG (Buspirone HC), Give 1 tablet by mouth every morning and at bedtime with a start date of 07/04/24.
Record review of Resident #22's MAR for June 2025 reflected he had received his ordered buspirone every day, twice a day for the month of June 2025.
Record review of Resident #22's Care Plan, revised on 01/06/25, reflected the following: Focus: The resident has Anxiety [sic] and is on antianxiety r/t Buspirone .
Observation on 06/10/25 at 9:32 AM of Resident #22 revealed he was involved in an activity with other residents. Resident #22 did not appear to be able to answer questions regarding his medications due to his cognition level.
Interview on 06/12/25 at 9:51 AM with RN E revealed she usually included an indication for use in a resident's medication order once it was entered onto the chart. RN E said Resident #22 was prescribed buspirone for his anxiety disorder.
2. Record review of Resident #54's admission Record, dated 06/12/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE].
Record review of Resident #54's Quarterly MDS Assessment, dated 04/20/25, reflected she had a BIMS score of 00 indicating severe cognitive impairment. Her active diagnoses included Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills, eventually impairing the ability to carry out simple tasks), anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, or dread that interferes with daily life), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Her MDS indicated she received antidepressants.
Record review of Resident #54's Order Summary Report, dated 06/12/25, reflected the following:
Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCI), Give 1 capsule by mouth at bedtime with a start date of 03/31/25.
Record review of Resident #54's MAR for June 2025 reflected she had received her ordered Cymbalta every day for the month of June 2025.
Record review of Resident #54's Care Plan, revised on 04/23/25, reflected the following: Focus: The resident uses antidepressant medication r/t Depression .
Interview on 06/12/25 at 10:05 AM with LVN F revealed Resident #54 was receiving Cymbalta for her depression. LVN F said normally when staff entered a medication order into the chart they included the indication for use or diagnosis as well because that was part of the process. LVN F said she was not sure why it was not originally included in the order.
Interview on 06/12/25 at 12:30 PM with the DON revealed the nurse who entered a resident's medication into their chart would also add an indication for use. The DON said normally the nurse managers checked to see that was completed during care plan meetings with that resident. The DON said staff were trained to ensure they included the indication for use or diagnosis related to a medication that a resident was taken. The DON said there was no risk for not having an indication for use included with a medication order in a resident's chart.
Record review of the facility's Medication and Treatment Orders policy, dated 2001, reflected the following: .9. Orders for medications must include: e. clinical condition or symptoms for which the medication is prescribed .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure that a resident who was incontinent of bladder rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of two residents (Residents #47 and #73) reviewed for catheter care.
The facility failed to ensure both Resident #47 and Resident #73 had a physician's order for an indwelling catheter.
This failure could place residents who had incontinence at risk for infections and improper treatment.
Findings included:
Record review of Resident #47's face sheet dated 06/12/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE].
Record review of Resident #47's Comprehensive MDS assessment dated [DATE] reflected Resident #47 had a BIMS score of 05 indicating Resident #47 had a severe cognitive impairment with diagnoses including Depression (persistent feeling of sadness), Anxiety Disorder (mental health conditions of excessive fear, worry, dread that interferes with daily life), hypertension (high blood pressure) and Alzheimer's Disease (progressive brain disorder slowly damaging memory, thinking, and behavior). The MDS reflected Resident #47 had use of an indwelling catheter.
Record review of Resident #47's undated care plan reflected Resident #47 had indwelling Suprapubic Catheter. Goal: Resident will be/remain free from catheter-related trauma. Interventions included Catheter: last changed 05/15/25, change catheter monthly. Catheter: The resident has 16fr indwelling suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to medical doctor for signs/systems of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
Record review of Resident #47's Treatment Administration Record for June 2025 revealed.
Document Output every shift start date 04/28/25 -06/12/25.
Record urinary output each shift start date 05/16/25-06/12/25.
Suprapubic catheter care every shift start date 04/28/25.
Change Suprapubic catheter as needed when compromised as needed start date 05/14/25.
Record review of Resident #47's physician's orders did not reflect an order for catheter use or what French gage required however the orders revealed:
Change Suprapubic catheter PRN when compromised as needed.
Active
5/14/2025
Change suprapubic catheter on the 15th of every month evening shift.
every evening shift starting on the 15th and ending on the 15th every month.
Active
5/15/2025
Document Output every shift.
Active
4/28/2025
Suprapubic catheters care every shift.
Active
4/28/2025
ENHANCED BARRIER PRECAUTION EVERY SHIFT: SUPRAPUBIC CATHETER
No directions specified for order.
Active
4/28/2025
Interview on 06/10/25 at 9:07 AM with Resident #47 revealed he did have a catheter, which he emptied himself and had no issues or concerns with it. Resident #47 stated staff was very helpful with it. Resident #47 was not able to express his need for the catheter.
Interview on 06/11/25 at 1:57 PM with LVN A revealed she was aware that Resident #47 required use of a catheter. According to LVN A she was not able to locate an order for use of the catheter, which should have included the proper gauge to use for replacement. LVN A stated she checked him earlier and she did not have any concerns with his catheter. LVN A stated the admitting nurse was responsible for ensuring the catheter order was entered upon admission. LVN A stated the ADON and the DON would be responsible to verify that all orders were entered. LVN A said not having an order for use of the catheter placed Resident #47 at risk of staff using the wrong supplies, however staff should replace the same gage as they took out.
Record review on 06/11/25 at 3:03 PM with LVN A, revealed she wanted the surveyor to see an order for Resident #47's catheter use had been added. The physician's order revealed:
Change suprapubic catheter on the 15th of every month evening shift. Size16FR/10cc every evening shift starting on the 15th and ending on the 15th every month -Start Date- 06/15/2025. No further interview was completed with LVN A about the order not being complete.
2. Record review of Resident #73's face sheet dated 06/12/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE].
Record review of Resident #73's Comprehensive MDS assessment dated [DATE] reflected Resident #73 had a BIMS score of 11 indicating Resident #73 had moderate cognitive impairment with diagnoses including Obstructive uropathy (disorder that occurs when urine flow is obstructed), Depression (persistent feeling of sadness), Anxiety Disorder (mental health conditions of excessive fear, worry, dread that interferes with daily life), Psychotic Disorder (mental disorder characterized by a disconnection from reality), stroke (damage to the brain from disruption of blood supply), hypertension (high blood pressure) and Alzheimer's Disease (progressive brain disorder slowly damaging memory, thinking, and behavior). The MDS reflected Resident #73 had use of an indwelling catheter, with use of supervision or touching assistance with toileting.
Record review of Resident #73's undated care plan reflected Resident #73 had indwelling catheter related to enlarged prostate, terminal condition. Goal: Resident will be/remain free from catheter-related trauma. Interventions included to assist as needed with maintaining personal cleanliness. Catheter (16FF 10cc). Position catheter bag and tubing below the level of the bladder. Observe for and report to the nurse any complaints of discomfort on urination and increased frequency of urination. Secure catheter tubing to leg to minimize trauma to the insertion site and make sure that the tubing is free of kinks and urine is present in the tube. When providing assistance, observe for and report any of the following to the nurse: pain, burning, blood-tinged urine, foul smelling urine, change mental status, change in behavior, such as confusion, increased restlessness or wandering.
Record review of Resident #73's June 2025 Treatment Administration Record reflected:
Catheter care - Wash with soap and water around the insertion site daily and as needed start date 08/08/24.
May irrigate the indwelling catheter with 60mls of normal saline every shift as needed to maintain patency as needed for Obstructive uropathy. Start date 02/12/25.
Record review of Resident #73's physician's orders did not reflect an order for catheter use or what French gauge required; however, the orders reflected:
ENHANCED BARRIER PRECAUTION EVERY SHIFT: BPH (CATHETER)
every shift
Active
1/22/2025
Catheter care - Wash with soap and water around the insertion site daily and prn every day shift
Active
8/8/2024
Monitor the stat lock on the right thigh for skin integrity and that it is holding well. every shift
Active
8/1/2024
Ensure the placement of the catheter Q shift and that it is draining.
every shift
Active
8/1/2024
Document the output of the catheter every shift every shift.
Active
8/1/2024
Ensure that catheter is to gravity and draining Q shift every shift for catheter.
Active
8/1/2024
May irrigate the indwelling catheter with 60 mls of normal saline every shift PRN to maintain patency
as needed for Obstructive uropathy
Active
2/12/2025
Observation and interview on 06/10/25 at 9:43 AM revealed Resident #73 sitting in the dining room. The resident had a catheter hanging underneath his wheelchair, and it was covered with a blue bag. Resident #73 stated had a catheter, and he he did not have a problem with his catheter. Resident #73 was not able to express his need for the catheter.
Interview on 06/11/25 at 2:05 PM with LVN A revealed she was aware that Resident #73 required the use of a catheter. According to LVN A she was not able to locate an order for the use of the catheter, which should have included the proper gauge to use for replacement. LVN A stated Resident #73 was on hospice care, the nurse had entered earlier to check on resident. According to LVN A, she knew what size catheter gauge to use because the hospice nurse left supplies that included 16FR to be changed on the 15th of June. According to LVN A she was not aware the order for Resident #73 was not present, and the admitting nurse should have entered it upon his admission and the ADON/DON were responsible for ensuring all orders had been entered. LVN A stated there would not be any risk to Resident #73 not having an order for catheter use and correct gauge to use because nursing staff would look at the gauge they were removing and replace with the same gauge.
Record review of Resident #73's hospice care book revealed a document Physician Order dated 11/11/24 for Resident #73, physician written order Admit Diagnosis: .May change 16FR 10cc catheter as needed!
Interview on 06/12/25 at 12:20 PM with ADON A revealed she expected nurses to enter all orders upon admission of each resident. ADON A stated when she entered and checked orders, she ensured an order would be entered for catheter use and it included the gauge to use. ADON A stated there was no risk to residents because they would replace the same size gauge that they removed. ADON A stated, You can see the gauge at the tip of the catheter before you change it out therefore you will ensure you get the proper supplies before changing. ADON A stated nurses were responsible for entering the orders for catheter use, reviewing the orders, and changing the catheters per the order or as needed.
Interview on 06/12/25 at 12:24 PM with the DON revealed there should be an order for catheter use, care and it should include the gauge. The DON stated the admitting nurse should have entered the order upon his admission and the ADON should have reviewed the orders to ensure the orders for his care were entered. The DON stated not having the order for use and gauge size placed Resident #47 at risk of distress, however nurses are responsible for looking at the catheter to verify the size prior to changing it out.
Record review of the facility's Catheter Care, Urinary policy, dated 2001, reflected:
The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.
Review the resident's care plan to assess for any special needs of the resident.
Assemble the equipment and supplies as needed.
Record review of the facility's Charting and Documentation policy, dated 2001, reflected:
All services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Treatments or services performed is to be documented in the resident medical record.
Entries may only be recorded in the resident's clinical record by licensed personnel (RN, LVN, physician, therapist) in accordance with state law and facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for two of six residents (Resident #21 and Resident #38) reviewed for medication administration.
1. LVN G failed to administer Timolol Maleate Ophthalmic Solution 0.5 % (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma) to Residents #21 and #38 as ordered by the physician.
2. LVN A failed to order Timolol maleate Ophthalmic solution 0.5% (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma) for Residnet#21 and #38 after administering the last dose on 06/10/25.
These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.
Findings included:
1. Record review of Resident #21's quarterly MDS assessment, dated 04/13/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident's cognition was severely impaired with a BIMS of 7. The resident had diagnosis which included acute angle-closure glaucoma, unspecified eye (is an ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor).
Record review of Resident #21's June 2025 Physician's Orders revealed Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma.
Observation on 06/11/25 at 09:11 AM revealed LVN G prepared medications outside of Resident's#21's room. She failed to administer Timolol Maleate Solution 0.5%. Instill 1 drop in both eyes in the morning for glaucoma making Resident #21 miss the morning dose.
2. Record review of Resident #38's comprehensive MDS assessment, dated 04/21/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS of 0. The resident had diagnoses which included unspecified glaucoma (is an ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor).
Record review of Resident 38's June 2025 Physician's Orders revealed Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma.
Observation on 06/11/25 at 09:18 AM revealed LVN G prepared medications for Resident #38. She failed to administer Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma making Resident #38 miss the morning dose.
Interview on 06/11/25 at 10:00 AM with LVN G regarding not administering Timolol Maleate Solution 0.5 % to Residents #21 and #38 for glaucoma as ordered by the doctor, she said she did not have the eye drops and she had ordered and had notified the doctor. She said it was all nurse's responsibility to order medications when they had a supply of three days left. LVN G stated the nurse that gave the last dose was supposed to reorder. She stated failure to refill the medication on time would cause the resident to miss doses and fail to get the therapy needed. She said she had in-services on medication administration and ordering. She stated she knew not giving the medication could result in having medication error and the glaucoma may get worse.
Interview with LVN A on 06/12/25 at 9:26 AM, regarding Resident#21 and Resident #38's Timolol Maleate Solution 0.5% eye drops, revealed she was the nurse who administered the last doses on 06/10/25 to both residents and she forgot to place a refill order to the pharmacy. She stated she got busy and forgot to refill the eye drops. She stated she forgot to notify the management. She stated it was the nurse's responsibility to refill and order medication when they had 1 week supply left. She stated it was nurses' responsibility to check the cart every shift and order what was missing. LVN A stated failure to order the medication on time would lead to the resident missing the medication and the glaucoma may worsen. She stated she had done in-services on medication administration.
Interview with the ADON on 06/12/25 at 12:23PM, she stated LVN A was the one that administered the last dose of the eye drops for both residents and she forgot to re-order for refill. She stated there was no specific time when nurse are supposed to order medications and she is new to the facility, and she is not aware of the facility protocol for refills. She stated the nurses are supposed to check carts and she follow up. She was not specific how often she follows up on checking the carts. She stated she was not a doctor to know the risk involved when Residents #21 and #38 missed the eye drops.
Interview on 06/12/25 at 1:31 PM with the DON revealed the nurses should follow the facility's policy for medication administration and ordering. She stated nurses should order when they had a 3 days' supply left. She said she was notified of the missed doses for Residents #21 and #38 and the eye drops were ordered. She stated the facility had a monthly pharmacy audit of the cart and the ADON was responsible for auditing the cart weekly. She could not recall when the carts were last audited. She stated the risk of the medication being missed depended on what medication was missed and they should notify the doctor for assessment of residents that had missed medications. The DON stated she had done skills check off with all nurses and she could not recall when.
Record review of the facility's training records on 06/12/15 revealed a medication administration in-service dated 01/29/25 and LVN A was in attendance.
Record review of the facility's Medication and Treatment Orders policy, dated July 2016, reflected:
.11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6.25% based on 2 errors out of 32 opportunities, which involved two of six residents (Resident #21 and Resident #38) reviewed for medication errors.
LVN G Failed to administer Timolol Maleate Ophthalmic Solution 0.5 % (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma ) to Residents #21 and #38 as ordered by the physician.
These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.
Findings included:
1. Record review of Resident #21's quarterly MDS assessment, dated 04/13/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident's cognition was severely impaired with a BIMS of 7. The resident had diagnosis which included acute angle-closure glaucoma, unspecified eye (is an ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor).
Record review of Resident #21's June 2025 Physician's Orders revealed Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma.
Observation on 06/11/25 at 09:11 AM revealed LVN G prepared medications outside of Resident's#21's room. She failed to administer Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma making Resident #21 miss the morning dose.
2. Record review of Resident #38's comprehensive MDS assessment, dated 04/21/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS of 0. The resident had diagnoses which included unspecified glaucoma (is an ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor).
Record review of Resident 38's June 2025 Physician's Orders revealed Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma.
Observation on 06/11/25 at 09:18 AM revealed LVN G prepared medications for Resident #38. She failed to administer Timolol Maleate Solution 0.5 %.Instill 1 drop in both eyes in the morning for glaucoma making Resident #38 miss the morning dose.
Interview on 6/11/25 at 10:00 AM with LVN G regarding not administering Timolol Maleate Solution 0.5 % to Residents #21 and #38 for glaucoma as ordered by the doctor, she said she did not have the eye drops and she had ordered and had notified the doctor. She said it was all nurse's responsibility to order medications when they had a supply of three days left. LVN G stated the nurse that gave the last dose was supposed to reorder. She stated failure to refill the medication on time would cause the resident to miss doses and fail to get the therapy needed. She said she had in-services on medication administration and ordering. She stated she knew not giving the medication could result in having medication error and the glaucoma may get worse.
Interview with LVN A on 6/12/25 at 09:26 AM, regarding Resident#21 and Resident #38's Timolol Maleate Solution 0.5 % eye drops , she revealed she was the nurse that administered the last doses on 6/10/25 to both residents and she forgot to place a refill order to the pharmacy. She stated she got busy and forgot to refill the eye drops. She stated she forgot to notify the management. She stated it was the nurse's responsibility to refill and order medication when they had 1 week supply left. She stated it was nurses' responsibility to check the cart every shift and order what was missing. LVN A stated failure to order the medication on time would lead to the resident missing the medication and the glaucoma may worsen. She stated she had done in-services on medication administration.
Interview with the ADON on 06/12/25 at 12:23PM, she stated LVN A was the one that administered the last dose of the eye drops for both residents and she forgot to re-order for refill. She stated there was no specific time when nurse are supposed to order medications and she is new to the facility, and she is not aware of the facility protocol for refills. She stated the nurses are supposed to check carts and she follow up. She was not specific how often she follows up on checking the carts. She stated she was not a doctor to know the risk involved when Resident #21 and #38 missed the eye drops.
Interview on 06/12/25 at 1:31 PM with DON revealed that nurses should follow the facility's policy for medication administration and ordering. She stated nurses should order when they had a 3 days' supply left. She said she was notified of the missed doses for Residents #21 and #38 and the eye drops were ordered. She stated the facility had a monthly pharmacy audit of the cart and the ADON was responsible for auditing the cart weekly. She could not recall when the carts were last audited. She stated the risk of the medication being missed depended on what medication was missed and they should notify the doctor for assessment of residents that had missed medications. The DON stated she had done skills check off with all nurses and she could not recall when.
Record review of the facility training records on 06/12/15 revealed a medication administration in-service dated 01/29/25 and LVN A was in attendance.
Record review of facility's policy on Medication and treatment orders dated July 2016, reflected:
.11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .
Oct 2024
5 deficiencies
4 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 7 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse.
The facility failed to ensure Resident #1 was free from physical and verbal abuse when CNA B pinned Resident #1's hands and arms to the bed, used his body weight on Resident #1 to force him to comply with receiving care and told Resident #1 not to play with him on 08/06/24.
An IJ was identified on 09/25/24. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 09/26/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.
This failure placed residents at risk for abuse.
Findings included:
Record review of Resident #1's face sheet, dated 09/26/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #1's Quarterly MDS Assessment, dated 07/22/24, reflected he had a BIMS score of 4 indicating severe cognitive impairment. Under the behavior section, there were no behaviors exhibited towards others nor were there any refusals or rejection of care. Under the functional abilities and goals section, it was noted that Resident #1 required partial/moderate assistance for upper and lower body dressing. Resident #1 had diagnoses of non-Alzheimer's Disease (any form of dementia other than Alzheimer's disease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized).
Record review of Resident #1's care plan reflected the following:
- Focus: [Resident #1] has an ADL self-care performance deficit r/t dementia .Goal: [Resident #1] will be encouraged to perform self care as his ability allows and will receive adequate assistance from staff to complete self-care tasks that he is not able to do on his own throughout this review period .Interventions: DRESSING: Allow sufficient time for dressing and undressing.
- Focus: [Resident #1] has a behavior problem r/t Dementia (Sometimes resistant to assistance with person care/ bathing. Strikes out and yells at staff) .Goal: [Resident #1] will have fewer behavior episodes by the review date .Interventions: Explain all procedures to [Resident #1] before starting and allow him time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Utilize dementia-specific care techniques to help alleviate [Resident #1's] fear and frustration during care. Use Positive Approach to Care, Validation techniques, Compassionate Tough, distraction, and redirection.
- Focus: [Resident #1] is resistive to care on occasions r/t Dementia .Goal: [Resident #1] will cooperate with care through the review date .Interventions: If [Resident #1] resists with ADLs, reassure him, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that [Resident #1] participates in the decision making process. Return at the agreed upon time.
Interview on 09/25/24 at 9:58 AM, Resident #1's RP revealed she saw through the camera in the resident's room on 08/06/24 that CNA B had abused Resident #1. Resident #1's RP said when she got to the facility she went straight to the DON's office and showed both the DON and ADON A the video on 08/06/24. Resident #1's RP said the DON told her she couldn't watch anymore of the video but the ADON watched the rest. Resident #1's RP said she was told they were going to remove CNA B from the floor. Resident #1's RP said she was sent down to talk to the Administrator. Resident #1's RP said the Administrator watched a little bit of the videos and Resident #1's RP told her that it wasn't the worst part, but that the Administrator did not want to see anymore. Resident #1's RP said the Administrator told her that CNA B would not be allowed to work at the facility again and they would report the information back to the agency where he worked. Resident #1's RP said she had asked them to have a nurse or someone to look at him for injuries because when she saw him he had a reddened area to his face. Resident #1's RP said she took a picture of the reddened area and showed the facility staff the picture from that day as well. Resident #1's RP said immediately after the incident, Resident #1 was very jumpy and acted scared when she or others got close to him which was unusual behavior for him.
Observation of Video #1 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:27:21 AM through 10:29:06 AM:
Resident #1 (who was a small and frail resident) was seen in bed, CNA B (who was a tall, heavy set man) walked into the frame of the camera and walked to the right side of the bed, opened up the cabinet and took a brief out and put it on the counter. CNA B moved the bedside table that was up against the wall so he could open the closet to get Resident #1's clothes out. CNA B set clothes on the bedside table. CNA B opened the cabinet again to get gloves out and set them on the bedside table. CNA B walked to a chair in the corner of Resident #1's room and sat down. CNA B said good morning and put the gloves on his hands. CNA B said We gotta get you up. Resident #1 said You can't get me up. You can't get me up. You can't get me up. The video ended.
Observation of Video #2 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:29:32 AM through 10:29:57 AM:
CNA B is still sitting in the chair in the corner of the room putting gloves on and said You don't think I can pick you up? We'll see. CNA B stood up. The video ended.
Observation of Video #3 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:30:02 AM through 10:35:25 AM:
CNA B walked to the left side of the resident's bed and turned the lights on. CNA B said My name is [CNA B's name]. and he leaned towards the resident. CNA B picked up the bed remote and started to raise the bed and head of Resident #1's bed. Resident #1 said something unintelligible. CNA B said something unintelligible. CNA B then pulled the covers away from Resident #1 while Resident #1 pulled them back. CNA B grabbed Resident #1's arms and held them away from the covers and told Resident #1 Hold on a second, hold on. CNA B kept taking the covers off of Resident #1 and then grabbed both of his arms and put them above the resident's head to hold them there while CNA B pulled his leg up to the bed and told Resident #1 I'm not playing with you. I'm not playing with you. I'm not playing with you. CNA B also said [something unintelligible] your friend. and then took the covers completely off of Resident #1 and laid them over the footboard of the bed. Resident #1 used his hands to grab at the sheet underneath him to try and cover himself and CNA B grabbed the sheet from the resident. CNA B pinned Resident #1's arms to the side of his head and held the resident there. Resident #1 said Get out the way. Get out the way. CNA B said I'm getting you up. Resident #1 said No. CNA B said Yes, I am. Resident #1 said something unintelligible. Resident #1 then turned to the side with the sheet in his hand where the aide was holding it and CNA B took his other hand and used it to check Resident #1's brief by pulling the back part of it out near his bottom area. CNA B took Resident #1's left hand and put it on his chest while CNA B put his knee on Resident #1's bed. CNA B then took his knee off the bed and turned the resident to the other side so he could use his other hand to remove the resident's brief from the right side. Resident #1's hands can be seen shaking in the video as he tried to reach down to stop CNA B. CNA B put his knee back on the bed while still holding the resident's hands down with his other hand. CNA B said [something unintelligible]. Do you want the sheet or do you want me to change you? What do you want to do? Pick one. You want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Resident #1 said No. CNA B said You want the sheet? You can have the sheet, I'm gonna change you. Resident #1 took his hands and tried pulling CNA B's hands away. CNA B took Resident #1's hands and tried pinning them above the residents head. Resident #1 said Hey! CNA B said I gotta change you. Resident #1 said No. CNA B said Yes. Resident #1 said No, you don't have to change me. CNA B said I do. CNA B crossed Resident #1's hands on his chest and held them there. Resident #1 tried to stop CNA B but he pushed his hands away. CNA B said Be careful now, be careful. CNA B took Resident #1's brief off and disappeared from the camera view with it then went to the right side of the bed to get Resident #1's pants and brief. CNA B walked to the left side of the bed, took the sheet from the bed and put it at the end of the bed. CNA B then opened up the brief. CNA B put the brief underneath Resident #1 and tried to turn him towards the aide but the resident started to try to pull the aide's hands off of him. CNA B then got on the bed again and forced Resident #1's hands and arms to his chest and told the resident Don't play with me repeatedly while holding the resident's hands and arms down. CNA B got on the resident's bed still holding onto the resident's upper arm. CNA B used his other hand to close the side of the resident's brief. The video ended.
Observation of Video #4 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:35:33 AM through 10:36:11 AM:
CNA B was on the resident's bed putting his brief on him but the residents hands kept trying to stop him. CNA B pinned Resident #1's hands to his face and when the resident resisted, he used his full body weight to lean on Resident #1, holding his arms down and said Don't bite me. CNA B got off Resident #1 but was still on the bed holding the resident's arms away from him and down on the bed while he used his other hand to secure the side of the resident's brief.
Observation of Video #5 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:36:10 AM through 10:38:11 AM:
CNA B was closing the side of the residents brief while Resident #1 had reached for the aides hand to stop him. CNA B leaned on the resident again with his full body weight and pinned the resident to the side of the bed. CNA B then faced away from the resident and had his knee tucked under him and his leg kicked out hanging off the bed. Resident #1 was laying on his right side and said something unintelligible. CNA B had his left elbow holding the residents arms down so the aide could attach the brief on the side. Resident #1 said Get out of my room. CNA B leaned off of the resident and then put his knees down on the bed and used his body weight on the resident to hold his arms down. CNA B and Resident #1 begin to physically struggle and the resident is heard grunting. CNA B took Resident #1's hands and held his arms down at the bedside. CNA B leans back and has his phone in his hand and gets off the bed and puts the phone in the pocket on the front of his scrubs. CNA B took Resident #1's pants from the left side of the bed and walked out of the frame with them. A door is heard being closed in the background. Resident #1 was seen trying to use the pillow between his legs to cover himself by putting it on top of his legs. CNA B came back into the frame of the camera and walks to the right side of the resident's bed and said Turn to the other side. Turn to the other side. CNA B took his phone out of his pocket to look at it and then put it back in his pocket. CNA B said Turn to the other side. Turn to the other side. Resident #1 held his hand up and shook his head no. CNA B said I've got to get you up, the doctor told me to get you up. CNA B then took the pillow off of the resident.
Observation of Video #6 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:38:15 AM through 10:40:17 AM:
CNA B took the incontinent pad from under the resident and folded it towards the resident's body and said This ain't me, it's the doctor. Resident #1 was using his hands to stop the aide. CNA B said It's the doctor. Resident #1 held his hands up in the air while the aide touched the side of his brief. CNA B said Hey, listen to me. [unintelligible words]. while Resident #1 tried to push the aide away and CNA B held the resident's arms down. CNA B put his left knee on the bed and started to hold the resident's arms down. Resident #1 said No. CNA B said something unintelligible while holding the resident's arms down. CNA B said Stop. Stop that alright. Resident #1 said something unintelligible to the aide. CNA B said [something unintelligible] good sense, okay. Resident #1 said Get out of my room. CNA B took his leg off the bed while still holding the residents arms down. Resident #1 said something unintelligible. CNA B let go of Resident #1 and put his finger near his face and said Don't do it. Resident #1 said something unintelligible as CNA B adjusted the side of his brief. Resident #1 can be seen breathing very heavily and had a scared look on his face. CNA B finished securing the side of the resident's brief and said Turn to the other side. While pointing to the other side of the room. CNA B turned the resident's body to the other side of the bed while the resident reached towards him to stop. CNA B said Didn't I tell you don't play with me? Resident #1 said something unintelligible. CNA B leaned towards Resident #1 and said something unintelligible to him. CNA B then pulled back from the resident and pulled his legs towards the middle of the bed and Resident #1 tried using his hands to stop the aide. CNA B got back on the bed with both of his knees and used his body weight to hold Resident #1 down on the left side of the bed. Resident #1 can be heard grunting while CNA B used his body weight to hold the resident down. CNA B tried to get Resident #1's brief up on the side of him. Resident #1 can be heard moaning and CNA B said I'm almost done. The video ended.
Observation of Video #7 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:40:44 AM through 10:42:43 AM:
CNA B was leaning on the resident and had the resident's pants on the bed and was trying to put them on the resident. Resident #1 can be seen struggling behind CNA B as the resident is pinned against the bed. CNA B used his elbow to hold the resident's arms down. CNA B said I told you not to do that. Resident #1 said No. and mumbled loudly. CNA B continued to put the resident's pants on his left leg and Resident #1 is still moaning. Resident #1 said something unintelligible as aide put his pants on his left leg. CNA B was still leaning on the resident pinning him against the side of the bed. Resident #1 said get out of my room. CNA B continued to put the pants on the resident and said Are you crazy? CNA B said something unintelligible twice. CNA B was holding onto the resident's grab bar on the left side of the resident's bed while using his elbow to keep the resident's arm from coming near him. CNA B was putting the resident's pants on. CNA B stopped and looked at the resident and then lifted off of him. Resident #1 put himself near the middle of the bed where his legs were and his pants were at his ankles. CNA B pulled the resident's legs towards him on the right side of the bed and the resident tried pulling his legs towards his chest and attempted to grab his legs from the aide. Resident #1 said Leave me alone. CNA B kept putting the resident's pants on his on his right leg while Resident #1 tried pulling the pants up on his leg to cover himself. Resident #1's hands were seen shaking. The video ended.
Observation of Video #8 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:42:51 AM through 10:43:26 AM:
CNA B was putting Resident #1's pants over his knees. Resident #1 tried grabbing the aide and the aide grabbed the resident back. CNA B put his knee on the bed to lean over the resident and took Resident #1's arms to cross them over his chest. CNA B said I don't play with you. I already told you. I don't told you. I already told you. Do not play with me. as he was leaning over the resident holding his arms to his chest. The video ended.
Observation of Video #9 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:43:26 AM through 10:45:24 AM:
CNA B eventually let go of the resident's arms that were crossed on his chest. CNA B got off the bed and started pulling the resident's pants up. CNA B walked to the other side of the bed to pull his pants up from the left side of the bed and pulled the residents legs towards him to lift the resident up under to pull the pants up on the backside. Resident #1's hands were shaking and he said something unintelligible. CNA B turned the resident away from him so Resident #1 was facing the right side of the bed and pulled the resident's pants up on the backside of him. Resident #1 turned his upper body towards CNA B. CNA B turned the residents legs towards him on the left side of the bed to pull his pants up on that side. CNA B let the resident's legs fall to the bed and walked around to the right side of the bed. Resident #1 can be seen heavily breathing and had a scared look on his face. CNA B took the shirt that was taken from the closet earlier from the bedside table and told the resident You're wearing something different. and put the shirt back in the closet. CNA B said I'm going to put you in something blue. and grabbed a blue shirt from the closet. CNA B walked around to the left side of the bed with the blue shirt. CNA B put the blue shirt on the footboard of the bed and said C'mon. Put your shirt on. and started to pull the resident's legs towards the left side of the bed towards the aide. CNA B then pulled the resident's arms to lift him to a more seated position on the side of the bed. CNA B said I got you. and started to pull the resident's shirt off of him. CNA B started to pull the shirt over his head and Resident #1 started to shake and breathe loudly. CNA B said I got you. and pulled the shirt off of Resident #1. The resident fell back onto the bed. CNA B rolled up the shirt and tossed it to the side of the room out of camera view. The video ended.
Observation of Video #10 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:45:29 AM through 10:47:28 AM:
CNA B was holding Resident #1's left arm down and said You're going to hurt yourself. CNA B used his right knee to hold the resident's left arm down by putting his knee on the resident's arm on the bed while he pulled the resident's left arm through the sleeve of the shirt. CNA B said Shit. CNA B got off the bed and said C'mon. while he pulled the residents arms to sit him up on the side of the bed. Resident #1 started punching the aide in his stomach area. CNA B took the resident's left arm and put it through the sleeve hole in the shirt. Resident #1 fell back to the bed and CNA B said I'm not playing with you. While he tried to get the resident's shirt on. Resident #1 said No. CNA B said something unintelligible twice. CNA B pulled the resident's shirt down and leaned back to stand in front of the resident and said You want your shoes on? Want your shoes on? Resident #1 nodded yes. CNA B walked out of the camera angle towards the wall in the room and Resident #1 was sitting on the side of the bed. CNA B sat next to the resident on the bed with his shoes in his hands. CNA B kicked his leg out to look at something, then put I back under him. CNA B took the Velcro straps off the resident's shoe and pulled the resident's leg up to put the shoe on. The video ended.
Observation and interview on 09/25/24 at 10:40 AM, with Resident #1 revealed he was laying in his bed in his room. Resident #1 said he was doing okay and was not in any pain. Resident #1 did not have any bruises or marks to his face. Resident #1 said someone was mean to him and hurt him, but could not specify who it was. Resident #1 said that he had seen the person who hurt him recently but was not able to say when he last saw them. Resident #1 appeared tired and stopped answering questions so the surveyor left the room.
Interview on 09/25/24 at 12:00 PM with LVN G revealed she cared for Resident #1. LVN G said Resident #1 had a behavior of refusing care and fighting staff when trying to care for him. LVN G said she never forced Resident #1 to receive care and instead would make sure he was safe and try again at a later time to provide him care if he refused. LVN G said she knew that physically forcing a resident to receive care was considered abuse.
Interview on 09/25/24 at 12:20 PM with RA C revealed he cared for Resident #1. RA C said Resident #1 did refuse care at times, so he would leave him alone and come back at a later time to try to provide care again. RA C said he would never force Resident #1 to receive care because that was a right the resident had to refuse.
Interview on 09/25/24 at 12:33 PM with CNA D revealed she cared for Resident #1. CNA D said Resident #1 sometimes refused care. CNA D said she would make sure Resident #1 was safe and would not force him to receive care. CNA D explained that she would try to provide care at a later time to Resident #1 and would not force him to receive care.
Interview on 09/25/24 at 12:44 PM with CNA E revealed he cared for Resident #1. CNA E said Resident #1 refused care sometimes. CNA E said he would not force Resident #1 to receive care and instead would make sure he was safe and try again at a later time to give care to him.
Interview on 09/25/24 at 12:53 PM with LVN F revealed she cared for Resident #1. LVN F said Resident #1 did refuse care at times. LVN F said she never forced Resident #1 to receive care and instead would make sure he was safe and would try again at a later time to provide the care to him. LVN F explained that physically forcing a resident to receive care was considered a form of abuse.
Interview on 09/25/24 at 1:44 PM with ADON A revealed she was familiar with Resident #1. ADON A said Resident #1 refused care but staff had been trained to come back at a different time if a resident refused care. ADON A said Resident #1's RP came to the facility one day and told her and the DON that she wanted to show them something. ADON A said Resident #1's RP showed a video of the aide attempting to provide care to Resident #1 but she could not recall the details of the video. ADON A said Resident #1's RP told them that she did not like the way the aide handled Resident #1 and did not want the aide to continue caring for the resident. ADON A said Resident #1's RP also showed them the picture of his face where there was redness to his face but she did not ask the RP how he got the redness. ADON A said Resident #1's RP expressed the redness was from the way the aide handled the resident. ADON A said she saw Resident #1 later that day and he did not have any redness noted to his face. ADON A said since she did not see the redness noted to Resident #1's face like in the picture she could not say that was how it happened or what caused it. ADON A said after she watched the videos, she went upstairs to take CNA B off the floor. ADON A said when she spoke with CNA B, he explained that Resident #1 was refusing care and being combative and he was trained to continue providing care when that happened. ADON A said after she talked with CNA B, he left the facility. ADON A said her impression of the video was that the aide was from an agency and that was not how the facility trained their own staff to handle resident refusals. ADON A said agency aides did not get any trainings from the facility when they pick up shifts for the facility. ADON A said their staff had been trained by the facility to make sure a resident was safe and then stop trying to provide care when they refused .
Interview on 09/25/24 at 2:11 PM with the DON revealed Resident #1 refused care at times and staff was supposed to give him a break and come back to reapproach or swap out with someone else to continue and provide care to him. The DON said one day Resident #1's RP came to her office and wanted to share a video with her. The DON said she asked Resident #1's RP to send the video to her but Resident #1's RP did not know how to do that. The DON said Resident #1's RP pulled up a video and the DON saw in the video Resident #1 put his hand up to say stop and that was enough for her to see. The DON said she told Resident #1's RP that if she wanted to share more about the situation, the best thing to do was to get the Administrator involved. The DON said Resident #1's RP also showed her the picture of Resident #1 that showed the redness on his face. The DON said when she went to see Resident #1 later that day she did not see any redness to his face, so whatever it was, it had resolved by the time she saw him. The DON said when she spoke with CNA B he said Resident #1 was fighting him during care and she explained to him that any time a resident refused care CNA B should stop. The DON said CNA B explained that he had been trained to continue providing care for a resident even if they had refused. The DON said there was no training provided to agency staff and she did not check their training before they picked up a shift at the facility. The DON said the facility used agency staff about one to three times per month, but it depended on staffing. The DON said it was appropriate for CNA B to continue providing care to Resident #1 even if he refused if that was how he had been trained even though it was not how the facility trained their staff. The DON said it was considered abuse if a staff member pinned a residents hands to the side of their head, above their head, and to their chest. The DON said another form of abuse could be a staff putting their body weight against a resident and using that to force the resident to comply while the staff ripped off the resident's brief and sheets .
Interview on 09/25/24 at 2:41 PM with the Administrator revealed Resident #1 refused care. The Administrator said facility staff had been trained to redirect a resident or give them a minute to try to get the resident focused on something else instead. The Administrator said Resident #1's RP came to her office to show her the videos and said that ADON A and the DON had already seen them. The Administrator said she saw there was a large male and he went into the room and provided care to Resident #1. The Administrator said she did not see anything on the video that was abusive. The Administrator said she asked Resident #1's RP if there was something worse on the video and was told no but it was not how the facility's staff would have handled the situation. The Administrator said Resident #1's RP brought up something about Resident #1's face and the DON told her that they did not see anything on his face. The Administrator said she never saw any other video but said the video she did see concerned her. The Administrator said agency staff were not given any training from the facility. The Administrator said the facility used agency staff about four to six times per month, but they tried to use their own staff as much as possible. The Administrator said if she thought anything CNA B did at that time was abusive, she would have reported it and completed an investigation. The Administrator began to watch the first part of video #3 that was provided by Resident #1's RP to the surveyor. The Administrator did not want to watch the whole video and only watched the first part of it where Resident #1 and CNA B were physically struggling with the covers. The Administrator said based on what she saw and what the surveyor told her had happened, that was considered abuse. The Administrator revealed she was the abuse coordinator for the facility. The Administrator explained that she was responsible for reporting and investigating allegations of abuse. The Administrator said all staff were responsible for ensuring residents were free from abuse and she expected all staff to follow the facility's abuse and neglect policy. The Administrator said if the facility's abuse policy was not followed that put residents at risk of injuries and psychological issues.
Interview via phone on 09/25/24 at 5:18 PM with CNA B revealed he was upset because the facility refused to allow him to write a statement about what happened. CNA B said he was working with an aggressive resident who bit him and hit him when he was working at the facility. CNA B said he restrained the resident while this was happening. CNA B said he did not receive any information on how to care for the resident before the start of his shift. CNA B said he guessed the resident was having PTSD since he was a veteran. CNA B said the residents at this facility were individuals who were aggressive on dementia wings. CNA B said he was told to get the resident ready and when he went into the room, the resident was ultra aggressive but once he calmed down everything was okay. CNA B said he walked into the resident's room and felt like he was blindsided. CNA B said he had been trained on caring for residents with dementia previously but he expected to be prepared to care for residents who fought and fought aggressively. CNA B said the resident struck him in the face and bit his arm while he was getting him prepared to sit in the chair to eat. CNA B said he had to restrain the resident to hold him back from hitting the aide. CNA B said he had been trained that if a resident was highly resistant to care to just back off and let them be but was in midst of caring for the resident before figuring out what happened. CNA B said he did not walk away from caring for the resident because he would pause in between incidents as if the episode was over and once the resident was dressed he stopped. CNA B said he did not feel he abused the resident by restraining him. When CNA B was asked about what he said to the resident in the video, he refused to answer. CNA B said he was not originally assigned to this resident but was asked to get him ready for the day so he did. The Administrator revealed she was the abuse coordinator for the facility and would be responsible for investigation and reporting any allegation of abuse. The Administrator said all staff were responsible for ensuring that residents were free from abuse. The Administrator said she expected all staff to follow the facility's abuse policy and not following it put residents at risk of injuries and psychological issues.
Record review of the facility's policy, revised March 2018, and titled Abuse and Neglect- Clinical Protocol reflected: 1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .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 facilitated or enabled through the use of technology.' .4. 'willful' as defined at [symbol]483.5 and as used in the definition of 'abuse,' means the 'individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' Cause Identific[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0604
(Tag F0604)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right to be free from physical restraints i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right to be free from physical restraints imposed for purpose of convenience and not required to treat the resident's medical symptoms was provided for 1 of 7 residents (Resident #1) reviewed for restraints.
The facility failed to ensure Resident #1 had the right to be free from restraints when CNA B physically pinned the resident's hands and arms to the bed while he provided care to him on 08/06/24.
After administrative review and IJ was identified on 10/11/24. The IJ template was provided to the facility on [DATE] at 8:30 AM. While the IJ was removed on 10/11/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.
This failure could place resident at risk of not being treated with respect and dignity, limit residents right to choose, take away independence, or cause severe injury.
Findings included:
Review of Resident #1's Quarterly MDS Assessment, dated 07/22/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. The MDS also reflected he had a BIMS of 4 indicating severe cognitive impairment. Under the behavior section, there were no behaviors exhibited towards others nor were there any refusals or rejection of care. Under the functional abilities and goals section, it was noted that Resident #1 required partial/moderate assistance for upper and lower body dressing. Resident #1 had diagnoses of non-Alzheimer's Disease (any form of dementia other than Alzheimer's disease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized).
Review of Resident #1's care plan reflected the following:
- Focus: [Resident #1] has an ADL self-care performance deficit r/t dementia .Goal: [Resident #1] will be encouraged to perform self-care as his ability allows and will receive adequate assistance from staff to complete self-care tasks that he is not able to do on his own throughout this review period .Interventions: DRESSING: Allow sufficient time for dressing and undressing.
- Focus: [Resident #1] has a behavior problem r/t Dementia (Sometimes resistant to assistance with person care/ bathing. Strikes out and yells at staff) .Goal: [Resident #1] will have fewer behavior episodes by the review date .Interventions: Explain all procedures to [Resident #1] before starting and allow him time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Utilize dementia-specific care techniques to help alleviate [Resident #1's] fear and frustration during care. Use Positive Approach to Care, Validation techniques, Compassionate Tough, distraction, and redirection.
- Focus: [Resident #1] is resistive to care on occasions r/t Dementia .Goal: [Resident #1] will cooperate with care through the review date .Interventions: If [Resident #1] resists with ADLs, reassure him, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that [Resident #1] participates in the decision making process. Return at the agreed upon time.
Interview on 09/25/24 at 9:58 AM with Resident #1's RP revealed she saw through the camera in the resident's room on 08/06/24 that CNA B had abused Resident #1. Resident #1's RP said when she got to the facility she went straight to the DON's office and showed both the DON and ADON A the video on 08/06/24. Resident #1's RP said the DON told her she could not watch anymore of the video but the ADON watched the rest. Resident #1's RP said she was told they were going to remove CNA B from the floor. Resident #1's RP said she was sent down to talk to the Administrator. Resident #1's RP said the Administrator watched a little bit of the videos and Resident #1's RP told her that it wasn't the worst part, but that the Administrator did not want to see anymore. Resident #1's RP said the Administrator told her that CNA B would not be allowed to work at the facility again and they would report the information back to the agency where he worked. Resident #1's RP said she asked them to have a nurse or someone to look at him for injuries because when she saw him he had a reddened area to his face. Resident #1's RP said she took a picture of the reddened area and showed the facility staff the picture from that day as well. Resident #1's RP said immediately after the incident, Resident #1 was very jumpy and acted scared when she or others got close to him which was unusual behavior for him.
Observation and interview on 10/11/24 at 12:47 PM, Resident #1 was self-propelling his wheelchair on the unit. The resident was very pleasant and was able to answer simple basic questions when asked. Resident #1 was asked how he was being treated and he smiled and said oh good and continued to wheel off. There were no bruising or suspicious injuries noted at the time of the interaction.
Observation of Video #1 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:27:21 AM through 10:29:06 AM:
Resident #1 (who was a small and frail resident) was seen in bed, CNA B (who was a tall, heavy set man) walked into the frame of the camera and walked to the right side of the bed, opened up the cabinet and took a brief out and put it on the counter. CNA B moved the bedside table that was up against the wall so he could open the closet to get Resident #1's clothes out. CNA B set clothes on the bedside table. CNA B opened the cabinet again to get gloves out and set them on the bedside table. CNA B walked to a chair in the corner of Resident #1's room and sat down. CNA B said good morning and put the gloves on his hands. CNA B said We gotta get you up. Resident #1 said You can't get me up. You can't get me up. You can't get me up. The video ended.
Observation of Video #3 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:30:02 AM through 10:35:25 AM:
CNA B walked to the left side of the resident's bed and turned the lights on. CNA B said My name is [CNA B's name]. and he leaned towards the resident. CNA B picked up the bed remote and started to raise the bed and head of Resident #1's bed. Resident #1 said something unintelligible. CNA B said something unintelligible. CNA B then pulled the covers away from Resident #1 while Resident #1 pulled them back. CNA B grabbed Resident #1's arms and held them away from the covers and told Resident #1 Hold on a second, hold on. CNA B kept taking the covers off of Resident #1 and then grabbed both of his arms and pinned them above the resident's head and held them there while CNA B pulled his leg up to the bed and told Resident #1 I'm not playing with you. I'm not playing with you. I'm not playing with you. CNA B also said [something unintelligible] your friend. and then took the covers completely off of Resident #1 and laid them over the footboard of the bed. Resident #1 used his hands to grab at the sheet underneath him to try and cover himself and CNA B grabbed the sheet from the resident. CNA B pinned Resident #1's arms to the side of his head and held the resident there. Resident #1 said Get out the way. Get out the way. CNA B said I'm getting you up. Resident #1 said No. CNA B said Yes, I am. Resident #1 said something unintelligible. Resident #1 then turned to the side with the sheet in his hand where the aide was holding it and CNA B took his other hand and used it to check Resident #1's brief by pulling the back part of it out near his bottom area. CNA B took Resident #1's left hand and put it on his chest while CNA B put his knee on Resident #1's bed. CNA B then took his knee off the bed and turned the resident to the other side so he could use his other hand to remove the resident's brief from the right side. Resident #1's hands can be seen shaking in the video as he tried to reach down to stop CNA B. CNA B put his knee back on the bed while still holding the resident's hands down with his other hand. CNA B said [something unintelligible]. Do you want the sheet or do you want me to change you? What do you want to do? Pick one. You want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Resident #1 said No. CNA B said You want the sheet? You can have the sheet, I'm gonna change you. Resident #1 took his hands and tried pulling CNA B's hands away. CNA B took Resident #1's hands and tried pinning them above the residents head. Resident #1 said Hey! CNA B said I gotta change you. Resident #1 said No. CNA B said Yes. Resident #1 said No, you don't have to change me. CNA B said I do. CNA B crossed Resident #1's hands on his chest and held them there. Resident #1 tried to stop CNA B but he pushed his hands away. CNA B said Be careful now, be careful. CNA B took Resident #1's brief off and disappeared from the camera view with it then went to the right side of the bed to get Resident #1's pants and brief. CNA B walked to the left side of the bed, took the sheet from the bed and put it at the end of the bed. CNA B then opened up the brief. CNA B put the brief underneath Resident #1 and tried to turn him towards the aide but the resident started to try to pull the aide's hands off of him. CNA B then got on the bed again and forced Resident #1's hands and arms to his chest and told the resident Don't play with me repeatedly while holding the resident's hands and arms down. CNA B got on the resident's bed still holding onto the resident's upper arm. CNA B used his other hand to close the side of the resident's brief. The video ended.
Observation of Video #4 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:35:33 AM through 10:36:11 AM:
CNA B was on the resident's bed putting his brief on him but the residents hands kept trying to stop him. CNA B pinned Resident #1's hands to his face and when the resident resisted, he used his full body weight to lean on Resident #1, holding his arms down and said Don't bite me. CNA B got off Resident #1 but was still on the bed holding the resident's arms away from him and down on the bed while he used his other hand to secure the side of the resident's brief.
Observation of Video #5 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:36:10 AM through 10:38:11 AM:
CNA B was closing the side of the residents brief while Resident #1 had reached for the aides hand to stop him. CNA B leaned on the resident again with his full body weight and pinned the resident to the side of the bed. CNA B then faced away from the resident and had his knee tucked under him and his leg kicked out hanging off the bed. Resident #1 was laying on his right side and said something unintelligible. CNA B had his left elbow holding the residents arms down so the aide could attach the brief on the side. Resident #1 said Get out of my room. CNA B leaned off of the resident and then put his knees down on the bed and used his body weight on the resident to hold his arms down. CNA B and Resident #1 begin to physically struggle and the resident is heard grunting. CNA B took Resident #1's hands and held his arms down at the bedside. CNA B leans back and has his phone in his hand and gets off the bed and puts the phone in the pocket on the front of his scrubs. CNA B took Resident #1's pants from the left side of the bed and walked out of the frame with them. A door is heard being closed in the background. Resident #1 was seen trying to use the pillow between his legs to cover himself by putting it on top of his legs. CNA B came back into the frame of the camera and walks to the right side of the resident's bed and said Turn to the other side. Turn to the other side. CNA B took his phone out of his pocket to look at it and then put it back in his pocket. CNA B said Turn to the other side. Turn to the other side. Resident #1 held his hand up and shook his head no. CNA B said I've got to get you up, the doctor told me to get you up. CNA B then took the pillow off of the resident.
CNA B took the incontinent pad from under the resident and folded it towards the resident's body and said This ain't me, it's the doctor. Resident #1 was using his hands to stop the aide. CNA B said It's the doctor. Resident #1 held his hands up in the air while the aide touched the side of his brief. CNA B said Hey, listen to me. [unintelligible words]. while Resident #1 tried to push the aide away and CNA B held the resident's arms down. CNA B put his left knee on the bed and started to hold the resident's arms down. Resident #1 said No. CNA B said something unintelligible while holding the resident's arms down. CNA B said Stop. Stop that alright. Resident #1 said something unintelligible to the aide. CNA B said [something unintelligible] good sense, okay. Resident #1 said Get out of my room. CNA B took his leg off the bed while still holding the residents arms down. Resident #1 said something unintelligible. CNA B let go of Resident #1 and put his finger near his face and said Don't do it. Resident #1 said something unintelligible as CNA B adjusted the side of his brief. Resident #1 can be seen breathing very heavily and had a scared look on his face. CNA B finished securing the side of the resident's brief and said Turn to the other side. While pointing to the other side of the room. CNA B turned the resident's body to the other side of the bed while the resident reached towards him to stop. CNA B said Didn't I tell you don't play with me? Resident #1 said something unintelligible. CNA B leaned towards Resident #1 and said something unintelligible to him. CNA B then pulled back from the resident and pulled his legs towards the middle of the bed and Resident #1 tried using his hands to stop the aide. CNA B got back on the bed with both of his knees and used his body weight to hold Resident #1 down on the left side of the bed. Resident #1 can be heard grunting while CNA B used his body weight to hold the resident down. CNA B tried to get Resident #1's brief up on the side of him. Resident #1 can be heard moaning and CNA B said I'm almost done. The video ended.
Observation of Video #7 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:40:44 AM through 10:42:43 AM:
CNA B was leaning on the resident and had the resident's pants on the bed and was trying to put them on the resident. Resident #1 can be seen struggling behind CNA B as the resident is pinned against the bed. CNA B used his elbow to hold the resident's arms down. CNA B said I told you not to do that. Resident #1 said No. and mumbled loudly. CNA B continued to put the resident's pants on his left leg and Resident #1 is still moaning. Resident #1 said something unintelligible as aide put his pants on his left leg. CNA B was still leaning on the resident pinning him against the side of the bed. Resident #1 said get out of my room. CNA B continued to put the pants on the resident and said Are you crazy? CNA B said something unintelligible twice. CNA B was holding onto the resident's grab bar on the left side of the resident's bed while using his elbow to keep the resident's arm from coming near him. CNA B was putting the resident's pants on. CNA B stopped and looked at the resident and then lifted off of him. Resident #1 put himself near the middle of the bed where his legs were and his pants were at his ankles. CNA B pulled the resident's legs towards him on the right side of the bed and the resident tried pulling his legs towards his chest and attempted to grab his legs from the aide. Resident #1 said Leave me alone. CNA B kept putting the resident's pants on his on his right leg while Resident #1 tried pulling the pants up on his leg to cover himself. Resident #1's hands were seen shaking. The video ended.
Observation of Video #8 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:42:51 AM through 10:43:26 AM:
CNA B was putting Resident #1's pants over his knees. Resident #1 tried grabbing the aide and the aide grabbed the resident back. CNA B put his knee on the bed to lean over the resident and took Resident #1's arms to cross them over his chest. CNA B said I don't play with you. I already told you. I don't told you. I already told you. Do not play with me. as he was leaning over the resident holding his arms to his chest. The video ended.
Observation of Video #10 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:45:29 AM through 10:47:28 AM:
CNA B was holding Resident #1's left arm down and said You're going to hurt yourself. CNA B used his right knee to hold the resident's left arm down by putting his knee on the resident's arm on the bed while he pulled the resident's left arm through the sleeve of the shirt. CNA B said Shit. CNA B got off the bed and said C'mon. while he pulled the residents arms to sit him up on the side of the bed. Resident #1 started punching the aide in his stomach area. CNA B took the resident's left arm and put it through the sleeve hole in the shirt. Resident #1 fell back to the bed and CNA B said I'm not playing with you. While he tried to get the resident's shirt on. Resident #1 said No. CNA B said something unintelligible twice. CNA B pulled the resident's shirt down and leaned back to stand in front of the resident and said You want your shoes on? Want your shoes on? Resident #1 nodded yes. CNA B walked out of the camera angle towards the wall in the room and Resident #1 was sitting on the side of the bed. CNA B sat next to the resident on the bed with his shoes in his hands. CNA B kicked his leg out to look at something, then put I back under him. CNA B took the Velcro straps off the resident's shoe and pulled the resident's leg up to put the shoe on. The video ended.
Telephone interview on 09/25/24 at 5:18 PM with CNA B revealed he was upset because the facility refused to allow him to write a statement about what happened. CNA B said he was working with an aggressive resident who bit him and hit him when he was working at the facility. CNA B said he restrained the resident while this was happening. CNA B said he did not receive any information on how to care for the resident before the start of his shift. CNA B said he guessed the resident was having PTSD since he was a veteran. CNA B said the residents at this facility were individuals who were aggressive on dementia wings. CNA B said he was told to get the resident ready and when he went into the room, the resident was ultra aggressive but once he calmed down everything was okay. CNA B said he walked into the resident's room and felt like he was blindsided. CNA B said he had been trained on caring for residents with dementia previously but he expected to be prepared to care for residents who fought and fought aggressively. CNA B said the resident struck him in the face and bit his arm while he was getting him prepared to sit in the chair to eat. CNA B said he had to restrain the resident to hold him back from hitting the aide. CNA B said he had been trained that if a resident was highly resistant to care to just back off and let them be but was in midst of caring for the resident before figuring out what happened. CNA B said he did not walk away from caring for the resident because he would pause in between incidents as if the episode was over and once the resident was dressed he stopped. CNA B said he did not feel he abused the resident by restraining him. When CNA B was asked about what he said to the resident in the video, he refused to answer. CNA B said he was not originally assigned to this resident but was asked to get him ready for the day so he did.
Interview on 10/11/24 at 8:35 AM with the Administrator and the DON revealed they were never made aware of the full video and never got to see Resident #1 being restrained while CNA B was providing care. Both the Administrator and the DON further stated they were only able to view a very small portion of the video where the aide was taking the resident shirt off when he was changing him. They said it appeared the aide did require more training and believed he had worked in a psychiatric facility where they were allowed to restrain people. The Administrator and DON further stated at no time and under no circumstances, were staff allowed to restrain a resident during care. If a resident became combative the staff were to back away and ensure the resident was safe, try again later and report to the charge nurse.
Record review of the facility's Abuse and Neglect-Clinical Protocol policy, revised March 2018, reflected:
1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .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 facilitated or enabled through the use of technology.' .4. 'willful' as defined at [symbol]483.5 and as used in the definition of 'abuse,' means the 'individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' Cause Identification, 1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes .Treatment/Management, 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations Monitoring and Follow-up .3. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process.
After Administrative review an Immediate Jeopardy was identified on 10/11/24. The Administrator and DON were notified of the Immediate Jeopardy on 10/11/24 at 8:30 AM. The IJ template was provided to the facility on [DATE] at 8:47 AM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.
The facility's Plan of Removal for the Immediate Jeopardy was accepted on 10/11/24 at 11:11 AM and reflected the following:
.Summary of Details which lead to outcomes:
On 10/11/24, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health regarding an incident on 8/6/24.
The notification of the alleged immediate jeopardy states as follows:
F 604-Failure to Ensure that a resident had the right to be free from physical restraints:
The facility failed to ensure a resident had the right to be free from physical restraints imposed for the purposes of discipline or convenience when CNA B (agency staff) physically restrained Resident #1 while providing the resident care after resident refusal.
Corrective actions for those found to have been affected by the deficient practice:
o
All residents have the potential to be affected. Identified resident remained in facility with no adverse reactions. The facility census on 8/6/24 was 105.
o
The identified agency CNA was placed on a do not return to the facility and notification was made to the agency manager regarding the allegations of abuse to include physical restraining of the resident.
o
Adhoc QAPI meeting held 10/11/24 to review current abuse and neglect policy including the no restraint policy and added additional procedures to ensure resident safety with agency staff.
o
All staff to be in-serviced over abuse and neglect to include no restraining of residents during care.
o
All allegations of abuse by anyone will be investigated and reported in adherence to Provider letter 2024-14.
o
Limit the use of agency staffing.
The training provided will be the following:
o
Abuse and neglect in-servicing will be done by DON and ADONs or designee. Training will be completed for our staff by 2:00pm 10/11/24. Staff that are on leave or not present for the in-service must be trained prior to working a shift on the floor. All Management staff will be retrained on abuse and neglect to include no restraining or residents during care.
o
Agency staff training before the start of their shift. lnservice packets will be left at each nursing station. Agency will review packet, signature of acknowledgement, and send signature page to staffing phone before starting shift. This training will now include no restraining of residents in any manner, including during care.
o
If any suspicion of negligent practice, will be reported to the agency manager, as well as any other reporting necessary to state providers. Abuse and neglect in-servicing including not using restraints will continue.
o
The administrator and [NAME] will be responsible for making sure the training is completed.
Ongoing monitoring:
o
All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved.
o
An Emergency QAPI meeting was conducted on 10/11/24. The Medical director was notified and agrees with the plan.
o
Agency staff will be reviewed for compliance to ensure that regulatory guidelines have been met for them to work in the facility.
Who is responsible for implementing of processes?
The administrative nurses (ADON and DON) and Administrator
Monitoring:
Record review of in-service records, dated 10/11/24, reflected the staff had been trained on abuse to include never to restrain a resident for any purpose. If a resident refuses care they are to ensure the resident was safe, report to the charge nurse and reapproach later to assist with care.
Interviews on 10/11/24 from 1:38 PM to 6:36 PM with the following staff from various shifts and days revealed if a resident became combative during care they were to step back make and ensure the resident was safe, report the incident to the charge nurse, and report to the charge nurse and try the care again later. Under no circumstances was a resident to be restrained during care. The staff included: CNA RR, CNA SS, CNA TT, LVN UU, LVN VV, LVN WW, CNA XX, CNA YY, CNA ZZ, CNA AAA, CNA K, CNA BBB, LVN CCC, CNA DDD, CNA EEE, CNA M, CNA N, LVN FFF, CNA GGG, LVN HHH, CNA III, RN JJJ, LVN U, CNA KKK, CNA BB, LVN LLL.
Observation on 10/11/24 from 12:17 PM to 1:17 PM revealed there were no agency staff working in any of the houses and there was an inservice binder that included the restraint inservice where any agency staff had to be inserviced on the facility's policy regarding abuse and restraints.
Observation on 10/11/24 from 12:17 PM to 1:17 PM revealed there were no concerns with the interactions between the staff and the residents in any of the houses.
Interview on 10/11/24 at 12:47 PM with three family members revealed they all had cameras in the resident rooms and they all stated they did not have any concerns regarding abuse or restraints.
After administrative review an IJ was identified on 10/11/24. The IJ template was provided to the facility on [DATE] at 8:30 AM. While the IJ was removed on 10/11/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on the Plan of Removal.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for 1 of 7 residents (Resident #1) reviewed for abuse.
The facility failed to implement the facility's written policies and procedures to prohibit and prevent abuse of Resident #1 when CNA B pinned Resident #1's hands and arms to the bed, used his body weight on Resident #1 to force him to comply with receiving care, and told Resident #1 not to play with him on 08/06/24.
The facility failed to ensure CNA B (an agency CNA) had been trained on how to care for Resident #1, a resident who refused care, and also had dementia training prior to beginning the shift.
An IJ was identified on 09/25/24. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 09/26/24, the facility remained out of compliance at a scope of isolated and a severity level of a potential for more than minimal harm because all staff had not been trained on the plan of removal.
This failure placed residents at risk for abuse.
Findings included:
Record review of the facility's Abuse and Neglect-Clinical Protocol policy, revised March 2018, reflected:
1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .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 facilitated or enabled through the use of technology.' .4. 'willful' as defined at [symbol]483.5 and as used in the definition of 'abuse,' means the 'individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' Cause Identification, 1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes .Treatment/Management, 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations Monitoring and Follow-up .3. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process.
Interview on 09/26/24 at 6:00 PM with the Administrator revealed the facility did not have a policy that addressed preventing abuse. The Administrator explained that the facility followed the provider letter 2024-14 as the facility's policy.
Record review of Resident #1's face sheet, dated 09/26/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #1's Quarterly MDS Assessment, dated 07/22/24, reflected he had a BIMS score of 4 indicating severe cognitive impairment. Under the behavior section, there were no behaviors exhibited towards others nor were there any refusals or rejection of care. Under the functional abilities and goals section, it was noted that Resident #1 required partial/moderate assistance for upper and lower body dressing. Resident #1 had diagnoses of non-Alzheimer's Disease (any form of dementia other than Alzheimer's disease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized).
Record review of Resident #1's care plan reflected the following:
- Focus: [Resident #1] has an ADL self-care performance deficit r/t dementia .Goal: [Resident #1] will be encouraged to perform self care as his ability allows and will receive adequate assistance from staff to complete self-care tasks that he is not able to do on his own throughout this review period .Interventions: DRESSING: Allow sufficient time for dressing and undressing.
- Focus: [Resident #1] has a behavior problem r/t Dementia (Sometimes resistant to assistance with person care/ bathing. Strikes out and yells at staff) .Goal: [Resident #1] will have fewer behavior episodes by the review date .Interventions: Explain all procedures to [Resident #1] before starting and allow him time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Utilize dementia-specific care techniques to help alleviate [Resident #1's] fear and frustration during care. Use Positive Approach to Care, Validation techniques, Compassionate Tough, distraction, and redirection.
- Focus: [Resident #1] is resistive to care on occasions r/t Dementia .Goal: [Resident #1] will cooperate with care through the review date .Interventions: If [Resident #1] resists with ADLs, reassure him, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that [Resident #1] participates in the decision making process. Return at the agreed upon time.
Interview on 09/25/24 at 9:58 AM with Resident #1's RP revealed she saw through the camera in the resident's room on 08/06/24 that CNA B had abused Resident #1. Resident #1's RP said when she got to the facility she went straight to the DON's office and showed both the DON and ADON A the video. Resident #1's RP said the DON told her she couldn't watch anymore of the video but the ADON watched the rest. Resident #1's RP said she was told they were going to remove CNA B from the floor. Resident #1's RP said she was sent down to talk to the Administrator. Resident #1's RP said the Administrator watched a little bit of the videos and Resident #1's RP told her that it wasn't the worst part, but that the Administrator did not want to see anymore. Resident #1's RP said the Administrator told her that CNA B would not be allowed to work at the facility again and they would report the information back to the agency where he worked. Resident #1's RP said she had asked them to have a nurse or someone to look at him for injuries because when she saw him he had a reddened area to his face. Resident #1's RP said she took a picture of the reddened area and showed the facility staff the picture from that day as well. Resident #1's RP said immediately after the incident, Resident #1 was very jumpy and acted scared when she or others got close to him which was unusual behavior for him.
Observation of Video #1 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:27:21 AM through 10:29:06 AM:
Resident #1 was seen in bed, CNA B walked into the frame of the camera and walked to the right side of the bed, opened up the cabinet and took a brief out and put it on the counter. CNA B moved the bedside table that was up against the wall so he could open the closet to get Resident #1's clothes out. CNA B set clothes on the bedside table. CNA B opened the cabinet again to get gloves out and set them on the bedside table. CNA B walked to a chair in the corner of Resident #1's room and sat down. CNA B said good morning and put the gloves on his hands. CNA B said We gotta get you up. Resident #1 said You can't get me up. You can't get me up. You can't get me up. The video ended.
Observation of Video #2 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:29:32 AM through 10:29:57 AM:
CNA B is still sitting in the chair in the corner of the room putting gloves on and said You don't think I can pick you up? We'll see. CNA B stood up. The video ended.
Observation of Video #3 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:30:02 AM through 10:35:25 AM:
CNA B walked to the left side of the resident's bed and turned the lights on. CNA B said My name is [CNA B's name]. and he leaned towards the resident. CNA B picked up the bed remote and started to raise the bed and head of Resident #1's bed. Resident #1 said something unintelligible. CNA B said something unintelligible. CNA B then pulled the covers away from Resident #1 while Resident #1 pulled them back. CNA B grabbed Resident #1's arms and held them away from the covers and told Resident #1 Hold on a second, hold on. CNA B kept taking the covers off of Resident #1 and then grabbed both of his arms and put them above the resident's head to hold them there while CNA B pulled his leg up to the bed and told Resident #1 I'm not playing with you. I'm not playing with you. I'm not playing with you. CNA B also said [something unintelligible] your friend. and then took the covers completely off of Resident #1 and laid them over the footboard of the bed. Resident #1 used his hands to grab at the sheet underneath him to try and cover himself and CNA B grabbed the sheet from the resident. CNA B pinned Resident #1's arms to the side of his head and held the resident there. Resident #1 said Get out the way. Get out the way. CNA B said I'm getting you up. Resident #1 said No. CNA B said Yes, I am. Resident #1 said something unintelligible. Resident #1 then turned to the side with the sheet in his hand where the aide was holding it and CNA B took his other hand and used it to check Resident #1's brief by pulling the back part of it out near his bottom area. CNA B took Resident #1's left hand and put it on his chest while CNA B put his knee on Resident #1's bed. CNA B then took his knee off the bed and turned the resident to the other side so he could use his other hand to remove the resident's brief from the right side. Resident #1's hands can be seen shaking in the video as he tried to reach down to stop CNA B. CNA B put his knee back on the bed while still holding the resident's hands down with his other hand. CNA B said [something unintelligible]. Do you want the sheet or do you want me to change you? What do you want to do? Pick one. You want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Resident #1 said No. CNA B said You want the sheet? You can have the sheet, I'm gonna change you. Resident #1 took his hands and tried pulling CNA B's hands away. CNA B took Resident #1's hands and tried pinning them above the residents head. Resident #1 said Hey! CNA B said I gotta change you. Resident #1 said No. CNA B said Yes. Resident #1 said No, you don't have to change me. CNA B said I do. CNA B crossed Resident #1's hands on his chest and held them there. Resident #1 tried to stop CNA B but he pushed his hands away. CNA B said Be careful now, be careful. CNA B took Resident #1's brief off and disappeared from the camera view with it then went to the right side of the bed to get Resident #1's pants and brief. CNA B walked to the left side of the bed, took the sheet from the bed and put it at the end of the bed. CNA B then opened up the brief. CNA B put the brief underneath Resident #1 and tried to turn him towards the aide but the resident started to try to pull the aide's hands off of him. CNA B then got on the bed again and forced Resident #1's hands and arms to his chest and told the resident Don't play with me repeatedly while holding the resident's hands and arms down. CNA B got on the resident's bed still holding onto the resident's upper arm. CNA B used his other hand to close the side of the resident's brief. The video ended.
Observation of Video #4 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:35:33 AM through 10:36:11 AM:
CNA B was on the resident's bed putting his brief on him but the residents hands kept trying to stop him. CNA B pinned Resident #1's hands to his face and when the resident resisted, he used his full body weight to lean on Resident #1, holding his arms down and said Don't bite me. CNA B got off Resident #1 but was still on the bed holding the resident's arms away from him and down on the bed while he used his other hand to secure the side of the resident's brief.
Observation of Video #5 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:36:10 AM through 10:38:11 AM:
CNA B was closing the side of the residents brief while Resident #1 had reached for the aides hand to stop him. CNA B leaned on the resident again with his full body weight and pinned the resident to the side of the bed. CNA B then faced away from the resident and had his knee tucked under him and his leg kicked out hanging off the bed. Resident #1 was laying on his right side and said something unintelligible. CNA B had his left elbow holding the residents arms down so the aide could attach the brief on the side. Resident #1 said Get out of my room. CNA B leaned off of the resident and then put his knees down on the bed and used his body weight on the resident to hold his arms down. CNA B and Resident #1 begin to physically struggle and the resident is heard grunting. CNA B took Resident #1's hands and held his arms down at the bedside. CNA B leans back and has his phone in his hand and gets off the bed and puts the phone in the pocket on the front of his scrubs. CNA B took Resident #1's pants from the left side of the bed and walked out of the frame with them. A door is heard being closed in the background. Resident #1 was seen trying to use the pillow between his legs to cover himself by putting it on top of his legs. CNA B came back into the frame of the camera and walks to the right side of the resident's bed and said Turn to the other side. Turn to the other side. CNA B took his phone out of his pocket to look at it and then put it back in his pocket. CNA B said Turn to the other side. Turn to the other side. Resident #1 held his hand up and shook his head no. CNA B said I've got to get you up, the doctor told me to get you up. CNA B then took the pillow off of the resident.
Observation of Video #6 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:38:15 AM through 10:40:17 AM:
CNA B took the incontinent pad from under the resident and folded it towards the resident's body and said This ain't me, it's the doctor. Resident #1 was using his hands to stop the aide. CNA B said It's the doctor. Resident #1 held his hands up in the air while the aide touched the side of his brief. CNA B said Hey, listen to me. [unintelligible words]. while Resident #1 tried to push the aide away and CNA B held the resident's arms down. CNA B put his left knee on the bed and started to hold the resident's arms down. Resident #1 said No. CNA B said something unintelligible while holding the resident's arms down. CNA B said Stop. Stop that alright. Resident #1 said something unintelligible to the aide. CNA B said [something unintelligible] good sense, okay. Resident #1 said Get out of my room. CNA B took his leg off the bed while still holding the residents arms down. Resident #1 said something unintelligible. CNA B let go of Resident #1 and put his finger near his face and said Don't do it. Resident #1 said something unintelligible as CNA B adjusted the side of his brief. Resident #1 can be seen breathing very heavily and had a scared look on his face. CNA B finished securing the side of the resident's brief and said Turn to the other side. While pointing to the other side of the room. CNA B turned the resident's body to the other side of the bed while the resident reached towards him to stop. CNA B said Didn't I tell you don't play with me? Resident #1 said something unintelligible. CNA B leaned towards Resident #1 and said something unintelligible to him. CNA B then pulled back from the resident and pulled his legs towards the middle of the bed and Resident #1 tried using his hands to stop the aide. CNA B got back on the bed with both of his knees and used his body weight to hold Resident #1 down on the left side of the bed. Resident #1 can be heard grunting while CNA B used his body weight to hold the resident down. CNA B tried to get Resident #1's brief up on the side of him. Resident #1 can be heard moaning and CNA B said I'm almost done. The video ended.
Observation of Video #7 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:40:44 AM through 10:42:43 AM:
CNA B was leaning on the resident and had the resident's pants on the bed and was trying to put them on the resident. Resident #1 can be seen struggling behind CNA B as the resident is pinned against the bed. CNA B used his elbow to hold the resident's arms down. CNA B said I told you not to do that. Resident #1 said No. and mumbled loudly. CNA B continued to put the resident's pants on his left leg and Resident #1 is still moaning. Resident #1 said something unintelligible as aide put his pants on his left leg. CNA B was still leaning on the resident pinning him against the side of the bed. Resident #1 said get out of my room. CNA B continued to put the pants on the resident and said Are you crazy? CNA B said something unintelligible twice. CNA B was holding onto the resident's grab bar on the left side of the resident's bed while using his elbow to keep the resident's arm from coming near him. CNA B was putting the resident's pants on. CNA B stopped and looked at the resident and then lifted off of him. Resident #1 put himself near the middle of the bed where his legs were and his pants were at his ankles. CNA B pulled the resident's legs towards him on the right side of the bed and the resident tried pulling his legs towards his chest and attempted to grab his legs from the aide. Resident #1 said Leave me alone. CNA B kept putting the resident's pants on his on his right leg while Resident #1 tried pulling the pants up on his leg to cover himself. Resident #1's hands were seen shaking. The video ended.
Observation of Video #8 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:42:51 AM through 10:43:26 AM:
CNA B was putting Resident #1's pants over his knees. Resident #1 tried grabbing the aide and the aide grabbed the resident back. CNA B put his knee on the bed to lean over the resident and took Resident #1's arms to cross them over his chest. CNA B said I don't play with you. I already told you. I don't told you. I already told you. Do not play with me. as he was leaning over the resident holding his arms to his chest. The video ended.
Observation of Video #9 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:43:26 AM through 10:45:24 AM:
CNA B eventually let go of the resident's arms that were crossed on his chest. CNA B got off the bed and started pulling the resident's pants up. CNA B walked to the other side of the bed to pull his pants up from the left side of the bed and pulled the residents legs towards him to lift the resident up under to pull the pants up on the backside. Resident #1's hands were shaking and he said something unintelligible. CNA B turned the resident away from him so Resident #1 was facing the right side of the bed and pulled the resident's pants up on the backside of him. Resident #1 turned his upper body towards CNA B. CNA B turned the residents legs towards him on the left side of the bed to pull his pants up on that side. CNA B let the resident's legs fall to the bed and walked around to the right side of the bed. Resident #1 can be seen heavily breathing and had a scared look on his face. CNA B took the shirt that was taken from the closet earlier from the bedside table and told the resident You're wearing something different. and put the shirt back in the closet. CNA B said I'm going to put you in something blue. and grabbed a blue shirt from the closet. CNA B walked around to the left side of the bed with the blue shirt. CNA B put the blue shirt on the footboard of the bed and said C'mon. Put your shirt on. and started to pull the resident's legs towards the left side of the bed towards the aide. CNA B then pulled the resident's arms to lift him to a more seated position on the side of the bed. CNA B said I got you. and started to pull the resident's shirt off of him. CNA B started to pull the shirt over his head and Resident #1 started to shake and breathe loudly. CNA B said I got you. and pulled the shirt off of Resident #1. The resident fell back onto the bed. CNA B rolled up the shirt and tossed it to the side of the room out of camera view. The video ended.
Observation of Video #10 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:45:29 AM through 10:47:28 AM:
CNA B was holding Resident #1's left arm down and said You're going to hurt yourself. CNA B used his right knee to hold the resident's left arm down by putting his knee on the resident's arm on the bed while he pulled the resident's left arm through the sleeve of the shirt. CNA B said Shit. CNA B got off the bed and said C'mon. while he pulled the residents arms to sit him up on the side of the bed. Resident #1 started punching the aide in his stomach area. CNA B took the resident's left arm and put it through the sleeve hole in the shirt. Resident #1 fell back to the bed and CNA B said I'm not playing with you. While he tried to get the resident's shirt on. Resident #1 said No. CNA B said something unintelligible twice. CNA B pulled the resident's shirt down and leaned back to stand in front of the resident and said You want your shoes on? Want your shoes on? Resident #1 nodded yes. CNA B walked out of the camera angle towards the wall in the room and Resident #1 was sitting on the side of the bed. CNA B sat next to the resident on the bed with his shoes in his hands. CNA B kicked his leg out to look at something, then put I back under him. CNA B took the Velcro straps off the resident's shoe and pulled the resident's leg up to put the shoe on. The video ended.
Observation and interview on 09/25/24 at 10:40 AM with Resident #1 revealed he was laying in his bed in his room. Resident #1 said he was doing okay and was not in any pain. Resident #1 did not have any bruises or marks to his face. Resident #1 said someone was mean to him and hurt him, but could not specify who it was. Resident #1 said that he had seen the person who hurt him recently but was not able to say when he last saw them. Resident #1 appeared tired and stopped answering questions so the surveyor left the room.
Interview on 09/25/24 at 12:00 PM with LVN G revealed she cared for Resident #1. LVN G said Resident #1 had a behavior of refusing care and fighting staff when trying to care for him. LVN G said she never forced Resident #1 to receive care and instead would make sure he was safe and try again at a later time to provide him care if he refused. LVN G said she knew that physically forcing a resident to receive care was considered abuse.
Interview on 09/25/24 at 12:20 PM with RA C revealed he cared for Resident #1. RA C said Resident #1 did refuse care at times, so he would leave him alone and come back at a later time to try to provide care again. RA C said he would never force Resident #1 to receive care because that was a right the resident had to refuse.
Interview on 09/25/24 at 12:33 PM with CNA D revealed she cared for Resident #1. CNA D said Resident #1 sometimes refused care. CNA D said she would make sure Resident #1 was safe and would not force him to receive care. CNA D explained that she would try to provide care at a later time to Resident #1 and would not force him to receive care.
Interview on 09/25/24 at 12:44 PM with CNA E revealed he cared for Resident #1. CNA E said Resident #1 refused care sometimes. CNA E said he would not force Resident #1 to receive care and instead would make sure he was safe and try again at a later time to give care to him.
Interview on 09/25/24 at 12:53 PM with LVN F revealed she cared for Resident #1. LVN F said Resident #1 did refuse care at times. LVN F said she never forced Resident #1 to receive care and instead would make sure he was safe and would try again at a later time to provide the care to him. LVN F explained that physically forcing a resident to receive care was considered a form of abuse.
Interview on 09/25/24 at 1:44 PM with ADON A revealed she was familiar with Resident #1. ADON A said Resident #1 refused care but staff had been trained to come back at a different time if a resident refused care. ADON A said Resident #1's RP came to the facility one day and told her and the DON that she wanted to show them something. ADON A said Resident #1's RP showed a video of the aide attempting to provide care to Resident #1 but she could not recall the details of the video. ADON A said Resident #1's RP told them that she did not like the way the aide handled Resident #1 and did not want the aide to continue caring for the resident. ADON A said Resident #1's RP also showed them the picture of his face where there was redness to his face but she did not ask the RP how he got the redness. ADON A said Resident #1's RP expressed the redness was from the way the aide handled the resident. ADON A said she saw Resident #1 later that day and he did not have any redness noted to his face. ADON A said since she did not see the redness noted to Resident #1's face like in the picture she could not say that was how it happened or what caused it. ADON A said after she watched the videos, she went upstairs to take CNA B off the floor. ADON A said when she spoke with CNA B, he explained that Resident #1 was refusing care and being combative and he was trained to continue providing care when that happened. ADON A said after she talked with CNA B, he left the facility. ADON A said her impression of the video was that the aide was from an agency and that was not how the facility trained their own staff to handle resident refusals. ADON A said agency aides did not get any trainings from the facility when they pick up shifts for the facility. ADON A said their staff had been trained by the facility to make sure a resident was safe and then stop trying to provide care when they refused.
Interview on 09/25/24 at 2:11 PM with the DON revealed Resident #1 refused care at times and staff were supposed to give him a break and come back to reapproach or swap out with someone else to continue and provide care to him. The DON said one day Resident #1's RP came to her office and wanted to share a video with her. The DON said she asked Resident #1's RP to send the video to her but Resident #1's RP did not know how to do that. The DON said Resident #1's RP pulled up a video and the DON saw in the video Resident #1 put his hand up to say stop and that was enough for her to see. The DON said she told Resident #1's RP that if she wanted to share more about the situation, the best thing to do was to get the Administrator involved. The DON said Resident #1's RP also showed her the picture of Resident #1 that showed the redness on his face. The DON said when she went to see Resident #1 later that day she did not see any redness to his face, so whatever it was, it had resolved by the time she saw him. The DON said when she spoke with CNA B he said Resident #1 was fighting him during care and she explained to him that any time a resident refused care CNA B should stop. The DON said CNA B explained that he had been trained to continue providing care for a resident even if they had refused. The DON said there was no training provided to agency staff and she did not check their training before they picked up a shift at the facility. The DON said the facility used agency staff about one to three times per month, but it depended on staffing. The DON said it was appropriate for CNA B to continue providing care to Resident #1 even if he refused if that was how he had been trained even though it was not how the facility trained their staff. The DON said it was considered abuse if a staff member pinned a residents hands to the side of their head, above their head, and to their chest. The DON said another form of abuse could be a staff putting their body weight against a resident and using that to force the resident to comply while the staff ripped off the resident's brief and sheets.
Interview on 09/25/24 at 2:41 PM with the Administrator revealed Resident #1 refused care. The Administrator said facility staff had been trained to redirect a resident or give them a minute to try to get the resident focused on something else instead. The Administrator said Resident #1's RP came to her office to show her the videos and said that the ADON and DON had already seen them. The Administrator said she saw there was a large male and he went into the room and provided care to Resident #1. The Administrator said she did not see anything on the video that was abusive. The Administrator said she asked Resident #1's RP if there was something worse on the video and was told no but it was not how the facility's staff would have handled the situation. The Administrator said Resident #1's RP brought up something about Resident #1's face and the DON told her that they did not see anything on his face. The Administrator said she never saw any other video but said the video she did see concerned her. The Administrator said agency staff were not given any training from the facility. The Administrator said the facility used agency staff about four to six times per month, but they tried to use their own staff as much as possible. The Administrator said if she thought anything CNA B did at that time was abusive, she would have reported it and completed an investigation. The Administrator began to watch the first part of video #3 that was provided by Resident #1's RP to the surveyor. The Administrator did not want to watch the whole video and only watched the first part of it where Resident #1 and CNA B were physically struggling with the covers. The Administrator said based on what she saw and what the surveyor told her had happened, that was considered abuse. The Administrator revealed she was the abuse coordinator for the facility and would be responsible for investigation and reporting any allegation of abuse. The Administrator said all staff were responsible for ensuring that residents were free from abuse. The Administrator said she expected all staff to follow the facility's abuse policy and not following it put residents at risk of injuries and psychological issues.
Telephone interview on 09/25/24 at 5:18 PM with CNA B revealed he was upset because the facility refused to allow him to write a statement about what happened. CNA B said he was working with an aggressive resident who bit him and hit him when he was working at the facility. CNA B said he restrained the resident while this was happening. CNA B said he did not receive any information on how to care for the resident before the start of his shift. CNA B said he guessed the resident was having PTSD since he was a veteran. CNA B said the residents at this facility were individuals who were aggressive on dementia wings. CNA B said he was told to get the resident ready and when he went into the room, the resident was ultra aggressive but once he calmed down everything was okay. CNA B said he walked into the resident's room and felt like he was blindsided. CNA B said he had been trained on caring for residents with dementia previously but he expected to be prepared to care for residents who fought and fought aggressively. CNA B said the resident struck in him in the face and bit his arm while he was getting him prepared to sit in the chair to eat. CNA B said he had to [TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroug...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 7 residents (Resident #1) reviewed for abuse.
The facility failed to implement their abuse policy and investigate alleged or suspected physical abuse when Resident #1's RP told them CNA B continued to provide care after the resident had refused and told them CNA B was rough during care leaving red marks to Resident #1's face.
An IJ was identified on 09/25/24. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 09/26/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.
This failure could place all residents at risk for abuse and psychosocial harm.
Findings included:
Record review of the facility's Abuse and Neglect- Clinical Protocol policy, revised March 2018, reflected:
1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .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 facilitated or enabled through the use of technology.' .4. 'willful' as defined at [symbol]483.5 and as used in the definition of 'abuse,' means the 'individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.'
Interview on 09/26/24 at 6:00 PM with the Administrator revealed the facility did not have a policy that addressed preventing abuse. The Administrator explained that the facility followed the provider letter 2024-14 as the facility's policy.
Record review of Resident #1's face sheet, dated 09/26/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #1's Quarterly MDS Assessment, dated 07/22/24, reflected he had a BIMS score of 4 indicating severe cognitive impairment. Under the behavior section, there were no behaviors exhibited towards others nor were there any refusals or rejection of care. Under the functional abilities and goals section, it was noted that Resident #1 required partial/moderate assistance for upper and lower body dressing. Resident #1 had diagnoses of non-Alzheimer's Disease (any form of dementia other than Alzheimer's disease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized).
Record review of Resident #1's care plan reflected the following:
- Focus: [Resident #1] has an ADL self-care performance deficit r/t dementia .Goal: [Resident #1] will be encouraged to perform self care as his ability allows and will receive adequate assistance from staff to complete self-care tasks that he is not able to do on his own throughout this review period .Interventions: DRESSING: Allow sufficient time for dressing and undressing.
-Focus: [Resident #1] has a behavior problem r/t Dementia (Sometimes resistant to assistance with person care/ bathing. Strikes out and yells at staff) .Goal: [Resident #1] will have fewer behavior episodes by the review date .Interventions: Explain all procedures to [Resident #1] before starting and allow him time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Utilize dementia-specific care techniques to help alleviate [Resident #1's] fear and frustration during care. Use Positive Approach to Care, Validation techniques, Compassionate Tough, distraction, and redirection.
- Focus: [Resident #1] is resistive to care on occasions r/t Dementia .Goal: [Resident #1] will cooperate with care through the review date .Interventions: If [Resident #1] resists with ADLs, reassure him, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that [Resident #1] participates in the decision making process. Return at the agreed upon time.
Interview on 09/25/24 at 9:58 AM with Resident #1's RP revealed she saw through the camera in the resident's room on 08/06/24 that CNA B had abused Resident #1. Resident #1's RP said when she got to the facility she went straight to the DON's office and showed both the DON and ADON A the video. Resident #1's RP said the DON told her she couldn't watch anymore of the video but the ADON watched the rest. Resident #1's RP said she was told they were going to remove CNA B from the floor. Resident #1's RP said she was sent down to talk to the Administrator. Resident #1's RP said the Administrator watched a little bit of the videos and Resident #1's RP told her that it wasn't the worst part, but that the Administrator did not want to see anymore. Resident #1's RP said the Administrator told her that CNA B would not be allowed to work at the facility again and they would report the information back to the agency where he worked. Resident #1's RP said she had asked them to have a nurse or someone to look at him for injuries because when she saw him he had a reddened area to his face. Resident #1's RP said she took a picture of the reddened area and showed the facility staff the picture from that day as well. Resident #1's RP said immediately after the incident, Resident #1 was very jumpy and acted scared when she or others got close to him which was unusual behavior for him.
Observation of Video #1 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:27:21 AM through 10:29:06 AM:
Resident #1 was seen in bed, CNA B walked into the frame of the camera and walked to the right side of the bed, opened up the cabinet and took a brief out and put it on the counter. CNA B moved the bedside table that was up against the wall so he could open the closet to get Resident #1's clothes out. CNA B set clothes on the bedside table. CNA B opened the cabinet again to get gloves out and set them on the bedside table. CNA B walked to a chair in the corner of Resident #1's room and sat down. CNA B said good morning and put the gloves on his hands. CNA B said We gotta get you up. Resident #1 said You can't get me up. You can't get me up. You can't get me up. The video ended.
Observation of Video #2 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:29:32 AM through 10:29:57 AM:
CNA B is still sitting in the chair in the corner of the room putting gloves on and said You don't think I can pick you up? We'll see. CNA B stood up. The video ended.
Observation of Video #3 provided by Resident #1's RP revealed the following occurred and was dated 08/06/24 at 10:30:02 AM through 10:35:25 AM:
CNA B walked to the left side of the resident's bed and turned the lights on. CNA B said My name is [CNA B's name]. and he leaned towards the resident. CNA B picked up the bed remote and started to raise the bed and head of Resident #1's bed. Resident #1 said something unintelligible. CNA B said something unintelligible. CNA B then pulled the covers away from Resident #1 while Resident #1 pulled them back. CNA B grabbed Resident #1's arms and held them away from the covers and told Resident #1 Hold on a second, hold on. CNA B kept taking the covers off of Resident #1 and then grabbed both of his arms and put them above the resident's head to hold them there while CNA B pulled his leg up to the bed and told Resident #1 I'm not playing with you. I'm not playing with you. I'm not playing with you. CNA B also said [something unintelligible] your friend. and then took the covers completely off of Resident #1 and laid them over the footboard of the bed. Resident #1 used his hands to grab at the sheet underneath him to try and cover himself and CNA B grabbed the sheet from the resident. CNA B pinned Resident #1's arms to the side of his head and held the resident there. Resident #1 said Get out the way. Get out the way. CNA B said I'm getting you up. Resident #1 said No. CNA B said Yes, I am. Resident #1 said something unintelligible. Resident #1 then turned to the side with the sheet in his hand where the aide was holding it and CNA B took his other hand and used it to check Resident #1's brief by pulling the back part of it out near his bottom area. CNA B took Resident #1's left hand and put it on his chest while CNA B put his knee on Resident #1's bed. CNA B then took his knee off the bed and turned the resident to the other side so he could use his other hand to remove the resident's brief from the right side. Resident #1's hands can be seen shaking in the video as he tried to reach down to stop CNA B. CNA B put his knee back on the bed while still holding the resident's hands down with his other hand. CNA B said [something unintelligible]. Do you want the sheet or do you want me to change you? What do you want to do? Pick one. You want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Do you want the sheet or do you want me to change you? Resident #1 said No. CNA B said You want the sheet? You can have the sheet, I'm gonna change you. Resident #1 took his hands and tried pulling CNA B's hands away. CNA B took Resident #1's hands and tried pinning them above the residents head. Resident #1 said Hey! CNA B said I gotta change you. Resident #1 said No. CNA B said Yes. Resident #1 said No, you don't have to change me. CNA B said I do. CNA B crossed Resident #1's hands on his chest and held them there. Resident #1 tried to stop CNA B but he pushed his hands away. CNA B said Be careful now, be careful. CNA B took Resident #1's brief off and disappeared from the camera view with it then went to the right side of the bed to get Resident #1's pants and brief. CNA B walked to the left side of the bed, took the sheet from the bed and put it at the end of the bed. CNA B then opened up the brief. CNA B put the brief underneath Resident #1 and tried to turn him towards the aide but the resident started to try to pull the aide's hands off of him. CNA B then got on the bed again and forced Resident #1's hands and arms to his chest and told the resident Don't play with me repeatedly while holding the resident's hands and arms down. CNA B got on the resident's bed still holding onto the resident's upper arm. CNA B used his other hand to close the side of the resident's brief. The video ended.
Observation of Video #4 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:35:33 AM through 10:36:11 AM:
CNA B was on the resident's bed putting his brief on him but the residents hands kept trying to stop him. CNA B pinned Resident #1's hands to his face and when the resident resisted, he used his full body weight to lean on Resident #1, holding his arms down and said Don't bite me. CNA B got off Resident #1 but was still on the bed holding the resident's arms away from him and down on the bed while he used his other hand to secure the side of the resident's brief.
Observation of Video #5 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:36:10 AM through 10:38:11 AM:
CNA B was closing the side of the residents brief while Resident #1 had reached for the aides hand to stop him. CNA B leaned on the resident again with his full body weight and pinned the resident to the side of the bed. CNA B then faced away from the resident and had his knee tucked under him and his leg kicked out hanging off the bed. Resident #1 was laying on his right side and said something unintelligible. CNA B had his left elbow holding the residents arms down so the aide could attach the brief on the side. Resident #1 said Get out of my room. CNA B leaned off of the resident and then put his knees down on the bed and used his body weight on the resident to hold his arms down. CNA B and Resident #1 begin to physically struggle and the resident is heard grunting. CNA B took Resident #1's hands and held his arms down at the bedside. CNA B leans back and has his phone in his hand and gets off the bed and puts the phone in the pocket on the front of his scrubs. CNA B took Resident #1's pants from the left side of the bed and walked out of the frame with them. A door is heard being closed in the background. Resident #1 was seen trying to use the pillow between his legs to cover himself by putting it on top of his legs. CNA B came back into the frame of the camera and walks to the right side of the resident's bed and said Turn to the other side. Turn to the other side. CNA B took his phone out of his pocket to look at it and then put it back in his pocket. CNA B said Turn to the other side. Turn to the other side. Resident #1 held his hand up and shook his head no. CNA B said I've got to get you up, the doctor told me to get you up. CNA B then took the pillow off of the resident.
Observation of Video #6 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:38:15 AM through 10:40:17 AM:
CNA B took the incontinent pad from under the resident and folded it towards the resident's body and said This ain't me, it's the doctor. Resident #1 was using his hands to stop the aide. CNA B said It's the doctor. Resident #1 held his hands up in the air while the aide touched the side of his brief. CNA B said Hey, listen to me. [unintelligible words]. while Resident #1 tried to push the aide away and CNA B held the resident's arms down. CNA B put his left knee on the bed and started to hold the resident's arms down. Resident #1 said No. CNA B said something unintelligible while holding the resident's arms down. CNA B said Stop. Stop that alright. Resident #1 said something unintelligible to the aide. CNA B said [something unintelligible] good sense, okay. Resident #1 said Get out of my room. CNA B took his leg off the bed while still holding the residents arms down. Resident #1 said something unintelligible. CNA B let go of Resident #1 and put his finger near his face and said Don't do it. Resident #1 said something unintelligible as CNA B adjusted the side of his brief. Resident #1 can be seen breathing very heavily and had a scared look on his face. CNA B finished securing the side of the resident's brief and said Turn to the other side. While pointing to the other side of the room. CNA B turned the resident's body to the other side of the bed while the resident reached towards him to stop. CNA B said Didn't I tell you don't play with me? Resident #1 said something unintelligible. CNA B leaned towards Resident #1 and said something unintelligible to him. CNA B then pulled back from the resident and pulled his legs towards the middle of the bed and Resident #1 tried using his hands to stop the aide. CNA B got back on the bed with both of his knees and used his body weight to hold Resident #1 down on the left side of the bed. Resident #1 can be heard grunting while CNA B used his body weight to hold the resident down. CNA B tried to get Resident #1's brief up on the side of him. Resident #1 can be heard moaning and CNA B said I'm almost done. The video ended.
Observation of Video #7 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:40:44 AM through 10:42:43 AM:
CNA B was leaning on the resident and had the resident's pants on the bed and was trying to put them on the resident. Resident #1 can be seen struggling behind CNA B as the resident is pinned against the bed. CNA B used his elbow to hold the resident's arms down. CNA B said I told you not to do that. Resident #1 said No. and mumbled loudly. CNA B continued to put the resident's pants on his left leg and Resident #1 is still moaning. Resident #1 said something unintelligible as aide put his pants on his left leg. CNA B was still leaning on the resident pinning him against the side of the bed. Resident #1 said get out of my room. CNA B continued to put the pants on the resident and said Are you crazy? CNA B said something unintelligible twice. CNA B was holding onto the resident's grab bar on the left side of the resident's bed while using his elbow to keep the resident's arm from coming near him. CNA B was putting the resident's pants on. CNA B stopped and looked at the resident and then lifted off of him. Resident #1 put himself near the middle of the bed where his legs were and his pants were at his ankles. CNA B pulled the resident's legs towards him on the right side of the bed and the resident tried pulling his legs towards his chest and attempted to grab his legs from the aide. Resident #1 said Leave me alone. CNA B kept putting the resident's pants on his on his right leg while Resident #1 tried pulling the pants up on his leg to cover himself. Resident #1's hands were seen shaking. The video ended.
Observation of Video #8 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:42:51 AM through 10:43:26 AM:
CNA B was putting Resident #1's pants over his knees. Resident #1 tried grabbing the aide and the aide grabbed the resident back. CNA B put his knee on the bed to lean over the resident and took Resident #1's arms to cross them over his chest. CNA B said I don't play with you. I already told you. I don't told you. I already told you. Do not play with me. as he was leaning over the resident holding his arms to his chest. The video ended.
Observation of Video #9 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:43:26 AM through 10:45:24 AM:
CNA B eventually let go of the resident's arms that were crossed on his chest. CNA B got off the bed and started pulling the resident's pants up. CNA B walked to the other side of the bed to pull his pants up from the left side of the bed and pulled the residents legs towards him to lift the resident up under to pull the pants up on the backside. Resident #1's hands were shaking and he said something unintelligible. CNA B turned the resident away from him so Resident #1 was facing the right side of the bed and pulled the resident's pants up on the backside of him. Resident #1 turned his upper body towards CNA B. CNA B turned the residents legs towards him on the left side of the bed to pull his pants up on that side. CNA B let the resident's legs fall to the bed and walked around to the right side of the bed. Resident #1 can be seen heavily breathing and had a scared look on his face. CNA B took the shirt that was taken from the closet earlier from the bedside table and told the resident You're wearing something different. and put the shirt back in the closet. CNA B said I'm going to put you in something blue. and grabbed a blue shirt from the closet. CNA B walked around to the left side of the bed with the blue shirt. CNA B put the blue shirt on the footboard of the bed and said C'mon. Put your shirt on. and started to pull the resident's legs towards the left side of the bed towards the aide. CNA B then pulled the resident's arms to lift him to a more seated position on the side of the bed. CNA B said I got you. and started to pull the resident's shirt off of him. CNA B started to pull the shirt over his head and Resident #1 started to shake and breathe loudly. CNA B said I got you. and pulled the shirt off of Resident #1. The resident fell back onto the bed. CNA B rolled up the shirt and tossed it to the side of the room out of camera view. The video ended.
Observation of Video #10 provided by Resident #1's RP revealed the following and was dated 08/06/24 at 10:45:29 AM through 10:47:28 AM:
CNA B was holding Resident #1's left arm down and said You're going to hurt yourself. CNA B used his right knee to hold the resident's left arm down by putting his knee on the resident's arm on the bed while he pulled the resident's left arm through the sleeve of the shirt. CNA B said Shit. CNA B got off the bed and said C'mon. while he pulled the residents arms to sit him up on the side of the bed. Resident #1 started punching the aide in his stomach area. CNA B took the resident's left arm and put it through the sleeve hole in the shirt. Resident #1 fell back to the bed and CNA B said I'm not playing with you. While he tried to get the resident's shirt on. Resident #1 said No. CNA B said something unintelligible twice. CNA B pulled the resident's shirt down and leaned back to stand in front of the resident and said You want your shoes on? Want your shoes on? Resident #1 nodded yes. CNA B walked out of the camera angle towards the wall in the room and Resident #1 was sitting on the side of the bed. CNA B sat next to the resident on the bed with his shoes in his hands. CNA B kicked his leg out to look at something, then put I back under him. CNA B took the Velcro straps off the resident's shoe and pulled the resident's leg up to put the shoe on. The video ended.
Observation and interview on 09/25/24 at 10:40 AM with Resident #1 revealed he was laying in his bed in his room. Resident #1 said he was doing okay and was not in any pain. Resident #1 did not have any bruises or marks to his face. Resident #1 said someone was mean to him and hurt him, but could not specify who it was. Resident #1 said that he had seen the person who hurt him recently but was not able to say when he last saw them. Resident #1 appeared tired and stopped answering questions so the surveyor left the room.
Interview on 09/25/24 at 1:44 PM with ADON A revealed she was familiar with Resident #1. ADON A said Resident #1 refused care but staff had been trained to come back at a different time if a resident refused care. ADON A said Resident #1's RP came to the facility one day and told her and the DON that she wanted to show them something. ADON A said Resident #1's RP showed a video of the aide attempting to provide care to Resident #1 but she could not recall the details of the video. ADON A said Resident #1's RP told them that she did not like the way the aide handled Resident #1 and did not want the aide to continue caring for the resident. ADON A said Resident #1's RP also showed them the picture of his face where there was redness to his face but she did not ask the RP how he got the redness. ADON A said Resident #1's RP expressed the redness was from the way the aide handled the resident. ADON A said she saw Resident #1 later that day and he did not have any redness noted to his face. ADON A said since she did not see the redness noted to Resident #1's face like in the picture she could not say that was how it happened or what caused it. ADON A said after she watched the videos, she went upstairs to take CNA B off the floor. ADON A said when she spoke with CNA B, he explained that Resident #1 was refusing care and being combative and he was trained to continue providing care when that happened. ADON A said after she talked with CNA B, he left the facility. ADON A said her impression of the video was that the aide was from an agency and that was not how the facility trained their own staff to handle resident refusals. ADON A said agency aides did not get any trainings from the facility when they pick up shifts for the facility. ADON A said their staff had been trained by the facility to make sure a resident was safe and then stop trying to provide care when they refused.
Interview on 09/25/24 at 2:11 PM with the DON revealed Resident #1 refused care at times and staff were supposed to give him a break and come back to reapproach or swap out with someone else to continue and provide care to him. The DON said one day Resident #1's RP came to her office and wanted to share a video with her. The DON said she asked Resident #1's RP to send the video to her but Resident #1's RP did not know how to do that. The DON said Resident #1's RP pulled up a video and the DON saw in the video Resident #1 put his hand up to say stop and that was enough for her to see. The DON said she told Resident #1's RP that if she wanted to share more about the situation, the best thing to do was to get the Administrator involved. The DON said Resident #1's RP also showed her the picture of Resident #1 that showed the redness on his face. The DON said when she went to see Resident #1 later that day she did not see any redness to his face, so whatever it was, it had resolved by the time she saw him. The DON said when she spoke with CNA B he said Resident #1 was fighting him during care and she explained to him that any time a resident refused care CNA B should stop. The DON said CNA B explained that he had been trained to continue providing care for a resident even if they had refused. The DON said there was no training provided to agency staff and she did not check their training before they picked up a shift at the facility. The DON said the facility used agency staff about one to three times per month, but it depended on staffing. The DON said it was appropriate for CNA B to continue providing care to Resident #1 even if he refused if that was how he had been trained even though it was not how the facility trained their staff. The DON said it was considered abuse if a staff member pinned a residents hands to the side of their head, above their head, and to their chest. The DON said another form of abuse could be a staff putting their body weight against a resident and using that to force the resident to comply while the staff ripped off the resident's brief and sheets.
Interview on 09/25/24 at 2:41 PM with the Administrator revealed Resident #1 refused care. The Administrator said facility staff had been trained to redirect a resident or give them a minute to try to get the resident focused on something else instead. The Administrator said Resident #1's RP came to her office to show her the videos and said that the ADON and DON had already seen them. The Administrator said she saw there was a large male and he went into the room and provided care to Resident #1. The Administrator said she did not see anything on the video that was abusive. The Administrator said she asked Resident #1's RP if there was something worse on the video and was told no but it was not how the facility's staff would have handled the situation. The Administrator said Resident #1's RP brought up something about Resident #1's face and the DON told her that they did not see anything on his face. The Administrator said she was not sure if the red marks seen on Resident #1's face in the picture provided by Resident #1's RP were from the situation with CNA B or not. The Administrator said it could have been from Resident #1 leaning on something or his pillow being creased but she did not do any follow up to see what caused it. The Administrator said she did not consider it abuse at the time. The Administrator said she never saw any other video but said the video she did see concerned her. The Administrator said agency staff were not given any training from the facility. The Administrator said the facility used agency staff about four to six times per month, but they tried to use their own staff as much as possible. The Administrator said if she thought anything CNA B did at that time was abusive, she would have reported it and completed an investigation. The Administrator began to watch the first part of video #3 that was provided by Resident #1's RP to the surveyor. The Administrator did not want to watch the whole video and only watched the first part of it where Resident #1 and CNA B were physically struggling with the covers. The Administrator said based on what she saw and what the surveyor told her had happened, that was considered abuse.
In a follow-up interview on 09/25/24 at 5:05 PM, the Administrator revealed she was the abuse coordinator for the facility. The Administrator explained that she was responsible for reporting and investigating allegations of abuse. The Administrator said all staff were responsible for ensuring residents were free from abuse and she expected all staff to follow the facility's abuse and neglect policy. The Administrator said if the facility's abuse policy was not followed that put residents at risk of injuries and psychological issues. The Administrator said since Resident #1's RP did not say what CNA B did in the videos was abusive, she did not think it needed to be reported or investigated further.
Telephone interview on 09/25/24 at 5:18 PM with CNA B revealed he was upset because the facility refused to allow him to write a statement about what happened. CNA B said he was working with an aggressive resident who bit him and hit him when he was working at the facility. CNA B said he restrained the resident while this was happening. CNA B said he did not receive any information on how to care for the resident before the start of his shift. CNA B said he guessed the resident was having PTSD since he was a veteran. CNA B said the residents at this facility were individuals who were aggressive on dementia wings. CNA B said he was told to get the resident ready and when he went into the room, the resident was ultra aggressive but once he calmed down everything was okay. CNA B said he walked into the resident's room and felt like he was blindsided. CNA B said he had been trained on caring for residents with dementia previously but he expected to be prepared to care for residents who fought and fought aggressively. CNA B said the resident struck in him in the face and bit his arm while he was getting him prepared to sit in the chair to eat. CNA B said he had to restrain the resident to hold him back from hitting the aide. CNA B said he had been trained that if a resident was highly resistant to care to just back off and let them be but was in midst of caring for the resident before figuring out what happened. CNA B said he did not walk away from caring for the resident because he would pause in between incidents as if the episode was over and once the resident was dressed he stopped. CNA B said he did not feel he abused the resident by restraining him. When CNA B was asked about what he said to the resident in the video, he refused to answer. CNA B said he was not originally assigned to this resident but was asked to get him ready for the day so he did.
An Immediate Jeopardy was identified on 09/25/24. The Administrator and DON were notified of the Immediate Jeopardy on 09/25/24 at 5:12 PM. The IJ template was provided to the facility on [DATE] at 5:17 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.
The facility's Plan of Removal for the Immediate Jeopardy was accepted on 09/26/24 at 10:57 AM and reflected the following:
.Summary of Details which lead to outcomes:
On 09/25/24, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health.
The notification of the alleged immediate jeopardy states as follows:
F610 Failure to be free from abuse:
Facility failed to have evidence that alleged violations in response to abuse and neglect were not investigated. The facility did not investigate the redness to the resident's face and did not investigate video footage that now shows the resident was verbally and physically abused by CNA B (agency staff).
Corrective actions for those found to have been affected by the deficient practice:
[TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to ensure that all alleged violations involving abuse, n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately to the State survey Agency in accordance with State law through( established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect.
The facility failed to report an abuse allegation made by Resident #1's RP's on 08/06/24 when it was alleged CNA B was rough and continued providing care to Resident #1 even though he refused leaving red marks to Resident #1's face.
This failure could place residents at risk for abuse and/or neglect .
Findings included:
Record review of the facility's Abuse and Neglect- Clinical Protocol policy, revised March 2018, reflected:
1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .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 facilitated or enabled through the use of technology.' .4. 'willful' as defined at [symbol]483.5 and as used in the definition of 'abuse,' means the 'individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' Cause Identification, 1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes .Treatment/Management, 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations Monitoring and Follow-up .3. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process.
Interview on 09/26/24 at 6:00 PM with the Administrator revealed the facility did not have a policy that addressed preventing abuse. The Administrator explained that the facility followed the provider letter 2024-14 as the facility's policy.
Record review of PL 2024-14, dated 08/29/24, and titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) reflected:
2.0 Policy Details & Provider Responsibilities, 2.1 Incidents that a NF Must Report to HHSC, A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse .Suspicious injuries of unknown source .
Record review of Resident #1's face sheet, dated 09/26/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].
Record review of Resident #1's Quarterly MDS Assessment, dated 07/22/24, reflected he had a BIMS of 4 indicating severe cognitive impairment. Under the behavior section, there were no behaviors exhibited towards others nor were there any refusals or rejection of care. Under the functional abilities and goals section, it was noted that Resident #1 required partial/moderate assistance for upper and lower body dressing. Resident #1 had diagnoses of non-Alzheimer's Disease (any form of dementia other than Alzheimer's disease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized).
Record review of Resident #1's care plan reflected the following:
- Focus: [Resident #1] has an ADL self-care performance deficit r/t dementia .Goal: [Resident #1] will be encouraged to perform self care as his ability allows and will receive adequate assistance from staff to complete self-care tasks that he is not able to do on his own throughout this review period .Interventions: DRESSING: Allow sufficient time for dressing and undressing.
- Focus: [Resident #1] has a behavior problem r/t Dementia (Sometimes resistant to assistance with person care/ bathing. Strikes out and yells at staff) .Goal: [Resident #1] will have fewer behavior episodes by the review date .Interventions: Explain all procedures to [Resident #1] before starting and allow him time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Utilize dementia-specific care techniques to help alleviate [Resident #1's] fear and frustration during care. Use Positive Approach to Care, Validation techniques, Compassionate Tough, distraction, and redirection.
- Focus: [Resident #1] is resistive to care on occasions r/t Dementia .Goal: [Resident #1] will cooperate with care through the review date .Interventions: If [Resident #1] resists with ADLs, reassure him, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that [Resident #1] participates in the decision making process. Return at the agreed upon time.
Interview on 09/25/24 at 9:58 AM with Resident #1's RP revealed she saw through the camera in the resident's room on 08/06/24 that CNA B had abused Resident #1. Resident #1's RP said when she got to the facility she went straight to the DON's office and showed both the DON and ADON A the video. Resident #1's RP said the DON told her she couldn't watch anymore of the video but the ADON watched the rest. Resident #1's RP said she was told they were going to remove CNA B from the floor. Resident #1's RP said she was sent down to talk to the Administrator. Resident #1's RP said the Administrator watched a little bit of the videos and Resident #1's RP told her that it wasn't the worst part, but that the Administrator did not want to see anymore. Resident #1's RP said the Administrator told her that CNA B would not be allowed to work at the facility again and they would report the information back to the agency where he worked. Resident #1's RP said she had asked them to have a nurse or someone to look at him for injuries because when she saw him he had a reddened area to his face. Resident #1's RP said she took a picture of the reddened area and showed the facility staff the picture from that day as well. Resident #1's RP said immediately after the incident, Resident #1 was very jumpy and acted scared when she or others got close to him which was unusual behavior for him.
Observation and interview on 09/25/24 at 10:40 AM with Resident #1 revealed he was laying in his bed in his room. Resident #1 said he was doing okay and was not in any pain. Resident #1 did not have any bruises or marks to his face. Resident #1 said someone was mean to him and hurt him, but could not specify who it was. Resident #1 said that he had seen the person who hurt him recently but was not able to say when he last saw them. Resident #1 appeared tired and stopped answering questions so the surveyor left the room.
Interview on 09/25/24 at 1:44 PM with ADON A revealed she was familiar with Resident #1. ADON A said Resident #1 refused care but staff had been trained to come back at a different time if a resident refused care. ADON A said Resident #1's RP came to the facility one day and told her and the DON that she wanted to show them something. ADON A said Resident #1's RP showed a video of the aide attempting to provide care to Resident #1 but she could not recall the details of the video. ADON A said Resident #1's RP told them that she did not like the way the aide handled Resident #1 and did not want the aide to continue caring for the resident. ADON A said Resident #1's RP also showed them the picture of his face where there was redness to his face but she did not ask the RP how he got the redness. ADON A said Resident #1's RP expressed the redness was from the way the aide handled the resident. ADON A said she saw Resident #1 later that day and he did not have any redness noted to his face. ADON A said since she did not see the redness noted to Resident #1's face like in the picture she could not say that was how it happened or what caused it. ADON A said after she watched the videos, she went upstairs to take CNA B off the floor. ADON A said when she spoke with CNA B, he explained that Resident #1 was refusing care and being combative and he was trained to continue providing care when that happened. ADON A said after she talked with CNA B, he left the facility. ADON A said her impression of the video was that the aide was from an agency and that was not how the facility trained their own staff to handle resident refusals. ADON A said agency aides did not get any trainings from the facility when they pick up shifts for the facility. ADON A said their staff had been trained by the facility to make sure a resident was safe and then stop trying to provide care when they refused.
Interview on 09/25/24 at 2:11 PM with the DON revealed Resident #1 refused care at times and staff were supposed to give him a break and come back to reapproach or swap out with someone else to continue and provide care to him. The DON said one day Resident #1's RP came to her office and wanted to share a video with her. The DON said she asked Resident #1's RP to send the video to her but Resident #1's RP did not know how to do that. The DON said Resident #1's RP pulled up a video and the DON saw in the video Resident #1 put his hand up to say stop and that was enough for her to see. The DON said she told Resident #1's RP that if she wanted to share more about the situation, the best thing to do was to get the Administrator involved. The DON said Resident #1's RP also showed her the picture of Resident #1 that showed the redness on his face. The DON said when she went to see Resident #1 later that day she did not see any redness to his face, so whatever it was, it had resolved by the time she saw him. The DON said when she spoke with CNA B he said Resident #1 was fighting him during care and she explained to him that any time a resident refused care CNA B should stop. The DON said CNA B explained that he had been trained to continue providing care for a resident even if they had refused. The DON said there was no training provided to agency staff and she did not check their training before they picked up a shift at the facility. The DON said the facility used agency staff about one to three times per month, but it depended on staffing. The DON said it was appropriate for CNA B to continue providing care to Resident #1 even if he refused if that was how he had been trained even though it was not how the facility trained their staff. The DON said it was considered abuse if a staff member pinned a residents hands to the side of their head, above their head, and to their chest. The DON said another form of abuse could be a staff putting their body weight against a resident and using that to force the resident to comply while the staff ripped off the resident's brief and sheets.
Interview on 09/25/24 at 2:41 PM with the Administrator revealed Resident #1 refused care. The Administrator said facility staff had been trained to redirect a resident or give them a minute to try to get the resident focused on something else instead. The Administrator said Resident #1's RP came to her office to show her the videos and said that the ADON and DON had already seen them. The Administrator said she saw there was a large male and he went into the room and provided care to Resident #1. The Administrator said she did not see anything on the video that was abusive. The Administrator said she asked Resident #1's RP if there was something worse on the video and was told no but it was not how the facility's staff would have handled the situation. The Administrator said Resident #1's RP brought up something about Resident #1's face and the DON told her that they did not see anything on his face. The Administrator said she was not sure if the red marks seen on Resident #1's face in the picture provided by Resident #1's RP were from the situation with CNA B or not. The Administrator said it could have been from Resident #1 leaning on something or his pillow being creased but she did not do any follow up to see what caused it. The Administrator said she did not consider it abuse at the time. The Administrator said she never saw any other video but said the video she did see concerned her. The Administrator said agency staff were not given any training from the facility. The Administrator said the facility used agency staff about four to six times per month, but they tried to use their own staff as much as possible. The Administrator said if she thought anything CNA B did at that time was abusive, she would have reported it and completed an investigation. The Administrator began to watch the first part of video #3 that was provided by Resident #1's RP to the surveyor. The Administrator did not want to watch the whole video and only watched the first part of it where Resident #1 and CNA B were physically struggling with the covers. The Administrator said based on what she saw and what the surveyor told her had happened, that was considered abuse.
In a follow-up interview on 09/25/24 at 5:05 PM, the Administrator revealed she was the abuse coordinator for the facility. The Administrator explained she was responsible for reporting and investigating allegations of abuse. The Administrator said all staff were responsible for ensuring residents were free from abuse and she expected all staff to follow the facility's abuse and neglect policy. The Administrator said if the facility's abuse policy was not followed that put residents at risk of injuries and psychological issues. The Administrator said since Resident #1's RP did not say what CNA B did in the videos was abusive, she did not think it needed to be reported or investigated further.
Telephone interview on 09/25/24 at 5:18 PM with CNA B revealed he was upset because the facility refused to allow him to write a statement about what happened. CNA B said he was working with an aggressive resident who bit him and hit him when he was working at the facility. CNA B said he restrained the resident while this was happening. CNA B said he did not receive any information on how to care for the resident before the start of his shift. CNA B said he guessed the resident was having PTSD since he was a veteran. CNA B said the residents at this facility were individuals who were aggressive on dementia wings. CNA B said he was told to get the resident ready and when he went into the room, the resident was ultra aggressive but once he calmed down everything was okay. CNA B said he walked into the resident's room and felt like he was blindsided. CNA B said he had been trained on caring for residents with dementia previously but he expected to be prepared to care for residents who fought and fought aggressively. CNA B said the resident struck in him in the face and bit his arm while he was getting him prepared to sit in the chair to eat. CNA B said he had to restrain the resident to hold him back from hitting the aide. CNA B said he had been trained that if a resident was highly resistant to care to just back off and let them be but was in midst of caring for the resident before figuring out what happened. CNA B said he did not walk away from caring for the resident because he would pause in between incidents as if the episode was over and once the resident was dressed he stopped. CNA B said he did not feel he abused the resident by restraining him. When CNA B was asked about what he said to the resident in the video, he refused to answer. CNA B said he was not originally assigned to this resident but was asked to get him ready for the day so he did.
Aug 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse.
The facility failed to ensure CNA B did not verbally and physically abuse Resident #1 on 04/29/24.
The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 04/29/24 and ended on 04/29/24. The facility had corrected the noncompliance before the investigation began.
This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm.
Findings included:
Review of Resident #1's electronic health record revealed she was an [AGE] year-old female who admitted to the facility on [DATE].
Review of Resident #1's quarterly MDS Assessment, dated 07/20/24, reflected she had a BIMS score of 02 indicating severe cognitive impairment. Further review revealed she had active diagnoses of Alzheimer's disease (a gradual decline in memory, thinking, behavior and social skills), non-Alzheimer's Dementia (a general term referring to changes in the brain that affect memory and the ability to perform daily abilities), and depression (a mood disorder that causes persistent sadness and loss of interest).
Review of Resident #1's care plan, dated 02/15/24, reflected the following: Focus: Resident has anxiety r/t confusion and fear due to dementia .Goal: Residents' anxiety will be controlled and there will be no adverse event related to psychosis in this review period .Interventions: Employ dementia-specific methods to help alleviate anxiety such as Compassionate Touch, Positive Approach to Care, Validation Therapy principles, redirection, and distraction.
Review of Resident #1's progress notes revealed the following:
- On 04/29/24 LVN A wrote: A call was received from family member who state that the CNA [CNA B] who was in [Resident #2's room] slapped [Resident #1] when she was pulling the bed control. [Resident #2's RP] got it on video and [Resident #2's RP] have already sent it to the DON. The CNA [CNA B] was removed from the unit and I immediately notified the administrator. A head to toe assessment was initiated, no apparent skin injury, redness, or bruising to resident's face or other parts of the body. The resident [Resident #1] denies pain or discomfort at this time no s/s of acute distress noted .MD/The administrator/DON/[Resident #1's RP C] was left a message to call back. I also called [Resident #1's RP D and Resident #1's RP E], but no answer.
Observation on 08/06/24 at 9:15 AM of Resident #1 revealed she was sitting in the dining room area at a table with two other residents. Resident #1 was looking to her side, away from the surveyor, and when approached did not make any eye contact or acknowledge the surveyor. Resident #1 did not appear to acknowledge the surveyor after multiple attempts to talk to her and ask questions. There were no visible marks or injuries to Resident #1's face.
An attempted telephone interview on 08/06/24 at 10:03 AM to Resident #1's RP C was unsuccessful as there was no answer.
Review of a video provided by the Administrator from Resident #2's RP was dated and time stamped as 04/29/2024 20:01:34 (8:01 PM) CDT in the bottom right corner revealed the following: CNA B was heard talking about someone going downstairs while Resident #1 entered the view of the camera first. CNA B walked in behind Resident #1, as Resident #1 stood in front of the bed, and the CNA B walked around the resident to the head of the bed. Resident #1 responded to CNA B saying, That's why I have to go downstairs and CNA B said something to the effect of Why do you want to go downstairs? and Resident #1 told her I can't go downstairs and sat on the side of Resident #2's bed while CNA B picked up the remote control for the bed. CNA B then told Resident #1 well get the hell out of here and Resident #1 replied saying, I have to have a [unintelligible word and motions with her hands towards herself]. CNA B started pressing a button on the remote control for the bed to lower the head of the bed and told Resident #1 well I don't give a damn. Resident #1 asked her why? and CNA B said to her Why should I? You don't give a damn about me. Resident #1 then reached towards CNA B to grab the cord part of the remote control for the bed, and the two begin to physically struggle over it for a second. CNA B then took her hand off the cord of the remote control for the bed and raised it to slap Resident #1 across her face. Resident #1 then fell back onto the bed and began calling CNA B a motherfucker while the two still physically struggled with the cord of the remote. Resident #1 tried to kick and push CNA B away from her while CNA B tried to take the remote control for the bed away from Resident #1. Resident #1 stood up from the bed and started walking backwards towards the entrance to the room while holding and pulling the cord to the remote control for the bed and called CNA B a motherfucker. CNA B then walked to Resident #1 trying to take the remote control for the bed away from her and told her, Didn't I tell you to get out of here? Resident #1 then told CNA B to shut up and then shut up you bitch. CNA B looked up into the camera a few times during this exchange while Resident #1 said these things to CNA B and kept telling her to shut up. CNA B was still trying to take the remote control for the bed away from Resident #1 while Resident #1 called CNA B a dirty, dirty, dirty, pushy, man. CNA B replied to Resident #1 saying I ain't no man and Resident #1 told her, Well I don't see a lot of men around you. And I see now why. CNA B then let go of the remote control for the bed and started walking away from Resident #1 towards the bed saying, Oh Lord [unintelligible word]. CNA B then walked up to the bed and pulled the top blanket and sheet back and took the pillow off the bed and placed it on the counter to the left of the bed. Resident #1 could be heard saying of course you do to CNA B. CNA B began stripping the sheets off the bed and Resident #1 pulled the cord for the remote control for the bed off and walked out of the frame of the camera. CNA B gathered up the linens she removed from the bed and walked out of the frame of the camera.
An attempted telephone interview on 08/06/24 at 11:23 AM to CNA B was unsuccessful as there was no answer or call back.
Review of an untitled and undated piece of paper provided by the facility reflected the following: To whom it may concern: I was walking in the room the resident was behind me talking mess while she grabbed me pushing me and I got away and went over to the bed. She came a sat on the bed while I was trying to make it she was still talking mess then she spit on me and my reaction kick in I wasn't trying to hit her but I did, I was trying to get the remote from her and she was holding on to it pulled it out of the bed and then I walked out .4/29/24 the abuse statement was from [CNA B]. She wrote this from 9:00p-9:15p tonight while waiting for [City Name] Police Department to arrive. (signed by the Administrator) [sic].
Review of a piece of paper, dated 5/3/24, reflected the following: Statement regarding intake number [xxxxxx]; On 4/29/24 around 8:15pm I got a call from the nurse [LVN A] that was working on [the unit] that evening. [LVN A] stated that [Resident #2's RP], the witness, called her and told her that he saw a CNA [CNA B] slap a female resident [Resident #1] in his [family member's] room. No other residents were in the room. I asked [LVN A] where the CNA [CNA B] was that he had accused. [LVN A] said she had the CNA, [CNA B], sitting with her and was not letting her around any residents per our policy .While speaking with [the DON] on the phone, we both got emails from [Resident #2's RP] that contained a video. As we watched the video, I stopped once the CNA [CNA B] struck the resident [Resident #1]. [the DON] called the facility and had the CNA [CNA B] wait downstairs in the lobby area .The resident [Resident #1] showed no signs of being slapped. There was no redness or anything. The resident [Resident #1] was in her bed getting ready for bed .I called the [City Name] Police department to come to [the facility] as soon as possible .[CNA B] admitted to striking the resident. She stated the resident [Resident #1] spit on her. I told her [CNA B] there was no evidence of the spitting and it didn't matter as there is no reason for her to ever hit a resident .The officers put her [CNA B] in handcuffs and arrested her after seeing the video .****Please note the incident took place in [Resident #2's] room which is [Resident #2's room number]. Neither [Resident #2] or [their] roommate were in the room .[CNA B] had entered the room with [Resident #1] following her. [CNA B] was attempting to change the linen on the bed. [Resident #1] was sitting on the bed. [CNA B] becomes verbally aggressive with [Resident #1] and [Resident #1] starts mimicking [CNA B]. [Resident #1] wanted the bed remote and that is when [CNA B] slapped her on the side of her face. At that point there is tussling over the bed remote and at some point [CNA B] lets her have it. [CNA B] continues to make the bed. [Resident #2's RP] was checking the video to check on his [family member] when he noticed that a woman [Resident #1] and the CNA [CNA B] were in the room and he saw the incident which then he sent the video to the DON and Administrator and called the nurse [LVN A] to make sure and call Administration. ***** .I called the victim's [Resident #1's] family. I explained the situation and they understood she is showing no signs of the slap and doesn't remember the incident. In servicing began that night and continued for several days regarding reporting and abuse and neglect. [sic] (signed by the Administrator).
In an interview via phone on 08/06/24 at 3:03 PM with LVN A revealed she was doing her normal nursing duties that evening on 04/29/24. LVN A said she saw CNA B and was told by her that Resident #1 had broken the remote control for the bed of the room that they were just in. LVN A said she would go and get a new one from the empty bed in another room. LVN A said CNA B went into Resident #2's room with her and helped to lift the mattress up and replace the remote control for the bed. LVN A said she went to the nurse's station a few moments later and received a call from a family member. LVN A said the family member said they saw CNA B slap Resident #1 in the room, and it was so bad, and they sent the video the management. LVN A said CNA B said nothing to her about it while they were fixing the remote control for the bed. LVN A said she thanked the family member and told CNA B to go downstairs and called the Administrator. LVN A said she assessed Resident #1, and she did not have any injuries to her. LVN A said the Administrator, the DON, and the police arrived to also check on Resident #1 after that, but CNA B was not on the floor anymore.
In an interview on 08/06/24 at 3:16 PM with the DON revealed she was at home and received a call that a staff member (CNA B) had slapped Resident #1. The DON said she called the facility and instructed them to take CNA B off the floor immediately. The DON said when she arrived at the facility, she went to check on Resident #1 to make sure she was safe and had no injuries. The DON said when she spoke with CNA B, she was told that Resident #1 was aggressive and trying to pull on the remote control for the bed. The DON said even with that behavior, no matter what, CNA B had no right to slap Resident #1. The DON said the police were called and CNA B was arrested and escorted off the property that evening on 04/29/24. The DON said all staff were in-serviced on abuse immediately and it was explained to them that any form of abuse would not be tolerated. The DON said she did watch the video that was sent by Resident #2's RP and saw that Resident #1 walked in pleasantly and sat on the end of the bed and had a conversation with CNA B. The DON said from her perspective, it appeared like Resident #1 was having a conversation with a friend. The DON said further into the conversation, after CNA B slapped her, Resident #1 stood at the door of the room waiting on her. The DON said LVN A told her that night she saw both Resident #1 and CNA B walking out of the room together holding CNA B's hand. The DON said there had never been any abuse allegations or accusations made against CNA B prior to this incident. The DON said CNA B had entered Resident #2's room to strip the bed because it was his shower day. The DON said Resident #1 was known to walk with staff often, so she assumed Resident #1 saw CNA B walk into Resident #2's room and just followed her. The DON said she and the police checked on Resident #1 three different times that evening and she had no recollection of what happened to her afterwards.
In an interview on 08/06/24 at 3:35 PM with the Administrator revealed she got a call from the nurse that Resident #2's RP told her that while he was looking at the camera, he saw CNA B slap a resident. The Administrator said she asked the nurse where CNA B was to which she told her she was right there with the nurse. The Administrator said she watched the video that was sent by Resident #2's RP and decided to drive to the facility. The Administrator said she instructed staff to send CNA B downstairs off the floor. The Administrator said when she saw Resident #1, she was not harmed and had no recollection of what happened to her. The Administrator said she gave CNA B a piece of paper to write down what happened and meanwhile she called the police. The Administrator said she started to fill out CNA B's termination paperwork and when she gave it to CNA B, CNA B was confused and refused to sign it. The Administrator said the police arrested CNA B onsite at the facility. The Administrator said she also called Resident #1's family to inform them of what happened. The Administrator said the DON began an in-service regarding abuse that evening on 04/29/24 with staff and continued until all staff had been in-serviced. The Administrator said she did watch the video, but it was hard for her to watch it. The Administrator said when she did watch the video, she saw Resident #1 sitting on the bed and CNA B was focused on making up the bed. The Administrator said she thought Resident #1 said she was going downstairs repeatedly and then somehow, she got the remote to the bed and did not let go. The Administrator said CNA B whacked Resident #1 and a loud pop could be heard on the video and Resident #1 began to scream and called CNA B names. The Administrator said later on someone told her they saw Resident #1 and CNA B walking to the nurse's station to say the bed remote was not working. The Administrator said she thought there was something very wrong in CNA B's head that night. The Administrator said she remembered hearing CNA B cursing at Resident #1 which was not appropriate at all. The Administrator said Resident #1 liked to follow staff around which was probably why she followed CNA B into Resident #2's room. The Administrator said there had never been any allegations or accusations against CNA B prior to this. The Administrator said employees should never abuse residents and everyone was aware of the policy to not abuse residents since they have a right to be free from abuse.
In an interview on 08/06/24 at 1:28 PM with CNA F revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 1:44 PM with CNA G revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 2:00 PM with CNA H revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 2:14 PM with LVN I revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
Review of an in-service, dated 04/25/24, revealed CNA B and other staff had been in-serviced regarding abuse and neglect.
Review of an in-service, dated 04/29/24, revealed staff had been in-serviced regarding abuse and neglect, stress management, and de-escalation strategies.
Review of an Employee Warning Notice for CNA B, dated 04/29/24, reflected under the Violation Type section an x was next to Inappropriate Behavior, Violation of Company Policies, and Other: Abuse. Further review under the section titled Description, including date(s) of incidents was: Admits to striking a resident. Under the section Actions to be Taken (verbal warning, written warning, final warning, termination) was Current Action: Termination. At the bottom of the page was signatures from the Administrator and DON with a note that read employee refused to sign.
Review of the facility's policy, revised March 2018, and titled Abuse and Neglect reflected: 1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, reasonable 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.'
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 3 residents (Resident #1) reviewed for abuse.
The facility failed to ensure Resident #1 was free from abuse per the policy.
The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 04/29/24 and ended on 04/29/24. The facility had corrected the noncompliance before the investigation began.
These failures could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse.
Findings included:
Review of the facility's policy, revised March 2018, and titled Abuse and Neglect reflected: 1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, reasonable 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.'
Review of the facility's undated policy, titled Abuse, Neglect, Exploitation, and Misappropriation of Property in Nursing Homes: What You Need to Know reflected: Abuse: Definition: a deliberate act that results in physical harm, pain, or mental anguish. It can be physical, verbal, sexual or mental. Abusers can be staff, residents, or visitors. There are four types of abuse- physical, verbal, mental, or sexual. Examples: rough handling, withholding care or assistance, isolating or restricting a resident, improper use of physical or chemical restraints, yelling, ridiculing, hitting, pushing, grabbing, or taking or using photographs or recordings of residents that would demean or humiliate a resident. Signs: unusual bruising, unexplained injury, sudden changes in a resident's behavior or activities .How Can Abuse, Neglect, Exploitation, and Misappropriation of Property be Prevented? Know and Exercise Your Rights: Right to be free from abuse, neglect, and exploitation .
Review of Resident #1's electronic health record revealed she was an [AGE] year-old female who admitted to the facility on [DATE].
Review of Resident #1's quarterly MDS Assessment, dated 07/20/24, reflected she had a BIMS score of 02 indicating severe cognitive impairment. Further review revealed she had active diagnoses of Alzheimer's disease (a gradual decline in memory, thinking, behavior and social skills), non-Alzheimer's Dementia (a general term referring to changes in the brain that affect memory and the ability to perform daily abilities), and depression (a mood disorder that causes persistent sadness and loss of interest).
Review of Resident #1's care plan, dated 02/15/24, reflected the following: Focus: Resident has anxiety r/t confusion and fear due to dementia .Goal: Residents' anxiety will be controlled and there will be no adverse event related to psychosis in this review period .Interventions: Employ dementia-specific methods to help alleviate anxiety such as Compassionate Touch, Positive Approach to Care, Validation Therapy principles, redirection, and distraction.
Review of Resident #1's progress notes revealed the following:
-On 04/29/24 LVN A wrote: A call was received from family member who state that the CNA [CNA B] who was in [Resident #2's room] slapped [Resident #1] when she was pulling the bed control. [Resident #2's RP] got it on video and [Resident #2's RP] have already sent it to the DON. The CNA [CNA B] was removed from the unit and I immediately notified the administrator. A head to toe assessment was initiated, no apparent skin injury, redness, or bruising to resident's face or other parts of the body. The resident [Resident #1] denies pain or discomfort at this time no s/s of acute distress noted .MD/The administrator/DON/[Resident #1's RP C] was left a message to call back. I also called [Resident #1's RP D and Resident #1's RP E], but no answer.
Observation on 08/06/24 at 9:15 AM of Resident #1 revealed she was sitting in the dining room area at a table with two other residents. Resident #1 was looking to her side, away from the surveyor, and when approached did not make any eye contact or acknowledge the surveyor. Resident #1 did not appear to acknowledge the surveyor after multiple attempts to talk to her and ask questions. There were no visible marks or injuries to Resident #1's face.
An attempted telephone interview on 08/06/24 at 10:03 AM to Resident #1's RP C was unsuccessful as there was no answer.
Review of a video provided by the Administrator from Resident #2's RP was dated and time stamped as 04/29/2024 20:01:34 (8:01 PM) CDT in the bottom right corner revealed the following: CNA B was heard talking about someone going downstairs while Resident #1 entered the view of the camera first. CNA B walked in behind her and Resident #1 stood in front of the bed and CNA B walked around her to the head of the bed. Resident #1 responded to her saying that's why I have to go downstairs and CNA B said something to the effect of why do you want to go downstairs? and Resident #1 told her I can't go downstairs and sat on the side of Resident #2's bed while CNA B picked up the remote control for the bed. CNA B then told Resident #1 well get the hell out of here and Resident #1 replied saying I have to have a [unintelligible word and motions with her hands towards herself]. CNA B started pressing a button on the remote control for the bed to lower the head of the bed and told Resident #1 well I don't give a damn. Resident #1 asked her why? and CNA B said to her why should I? You don't give a damn about me. Resident #1 then reached towards CNA B to grab the cord part of the remote control for the bed and the two begin to physically struggle over it for a second. CNA B then took her hand off the cord of the remote control for the bed and raised it to slap Resident #1 across her face. Resident #1 then fell back onto the bed and began calling CNA B a motherfucker while the two still physically struggled with the cord of the remote. Resident #1 tried to kick and push CNA B away from her while CNA B tried to take the remote control for the bed away from Resident #1. Resident #1 stood up from the bed and started walking backwards towards the entrance to the room while holding and pulling the cord to the remote control for the bed and called CNA B a motherfucker. CNA B then walked to Resident #1 trying to take the remote control for the bed away from her and tells her didn't I tell you to get out of here? and Resident #1 tells her to shut up and then shut up you bitch. CNA B looked up into the camera a few times during this exchange while Resident #1 said these things to CNA B and kept telling her to shut up. CNA B was still trying to take the remote control for the bed away from Resident #1 while Resident #1 called CNA B a dirty, dirty, dirty, pushy, man. CNA B replied to Resident #1 saying I ain't no man and Resident #1 told her, Well I don't see a lot of men around you. And I see now why. CNA B then let go of the remote control for the bed and started walking away from Resident #1 towards the bed saying, Oh Lord [unintelligible word]. CNA B then walked up to the bed and pulled the top blanket and sheet back and took the pillow off the bed and placed it on the counter to the left of the bed. Resident #1 could be heard saying of course you do to CNA B. CNA B began stripping the sheets off the bed and Resident #1 pulled the cord for the remote control for the bed off and walked out of the frame of the camera. CNA B gathered up the linens she removed from the bed and walked out of the frame of the camera.
An attempted telephone interview on 08/06/24 at 11:23 AM to CNA B was unsuccessful as there was no answer or call back.
Review of an untitled and undated piece of paper provided by the facility reflected the following: To whom it may concern: I was walking in the room the resident was behind me talking mess while she grabbed me pushing me and I got away and went over to the bed. She came a sat on the bed while I was trying to make it she was still talking mess then she spit on me and my reaction kick in I wasn't trying to hit her but I did, I was trying to get the remote from her and she was holding on to it pulled it out of the bed and then I walked out .4/29/24 the abuse statement was from [CNA B]. She wrote this from 9:00p-9:15p tonight while waiting for [City Name] Police Department to arrive. (signed by the Administrator) [sic].
Review of a piece of paper, dated 5/3/24, reflected the following: Statement regarding intake number [xxxxxx]; On 4/29/24 around 8:15pm I got a call from the nurse [LVN A] that was working on [the unit] that evening. [LVN A] stated that [Resident #2's RP], the witness, called her and told her that he saw a CNA [CNA B] slap a female resident [Resident #1] in his [family member's] room. No other residents were in the room. I asked [LVN A] where the CNA [CNA B] was that he had accused. [LVN A] said she had the CNA, [CNA B], sitting with her and was not letting her around any residents per our policy .While speaking with [the DON] on the phone, we both got emails from [Resident #2's RP] that contained a video. As we watched the video, I stopped once the CNA [CNA B] struck the resident [Resident #1]. [the DON] called the facility and had the CNA [CNA B] wait downstairs in the lobby area .The resident [Resident #1] showed no signs of being slapped. There was no redness or anything. The resident [Resident #1] was in her bed getting ready for bed .I called the [City Name] Police department to come to [the facility] as soon as possible .[CNA B] admitted to striking the resident. She stated the resident [Resident #1] spit on her. I told her [CNA B] there was no evidence of the spitting and it didn't matter as there is no reason for her to ever hit a resident .The officers put her [CNA B] in handcuffs and arrested her after seeing the video .****Please note the incident took place in [Resident #2's] room which is [Resident #2's room number]. Neither [Resident #2] or [their] roommate were in the room .[CNA B] had entered the room with [Resident #1] following her. [CNA B] was attempting to change the linen on the bed. [Resident #1] was sitting on the bed. [CNA B] becomes verbally aggressive with [Resident #1] and [Resident #1] starts mimicking [CNA B]. [Resident #1] wanted the bed remote and that is when [CNA B] slapped her on the side of her face. At that point there is tussling over the bed remote and at some point [CNA B] lets her have it. [CNA B] continues to make the bed. [Resident #2's RP] was checking the video to check on his [family member] when he noticed that a woman [Resident #1] and the CNA [CNA B] were in the room and he saw the incident which then he sent the video to the DON and Administrator and called the nurse [LVN A] to make sure and call Administration. ***** .I called the victim's [Resident #1's] family. I explained the situation and they understood she is showing no signs of the slap and doesn't remember the incident. In servicing began that night and continued for several days regarding reporting and abuse and neglect. [sic] (signed by the Administrator).
In an interview via phone on 08/06/24 at 3:03 PM with LVN A revealed she was doing her normal nursing duties that evening on 04/29/24. LVN A said she saw CNA B and was told by her that Resident #1 had broken the remote control for the bed of the room that they were just in. LVN A said she would go and get a new one from the empty bed in another room. LVN A said CNA B went into Resident #2's room with her and helped to lift the mattress up and replace the remote control for the bed. LVN A said she went to the nurse's station a few moments later and received a call from a family member. LVN A said the family member said they saw CNA B slap Resident #1 in the room, and it was so bad and they sent the video the management. LVN A said CNA B said nothing to her about it while they were fixing the remote control for the bed. LVN A said she thanked the family member and told CNA B to go downstairs and called the Administrator. LVN A said she assessed Resident #1, and she did not have any injuries to her. LVN A said the Administrator, the DON, and the police arrived to also check on Resident #1 after that, but CNA B was not on the floor anymore.
In an interview on 08/06/24 at 3:16 PM with the DON revealed she was at home and received a call that a staff member (CNA B) had slapped Resident #1. The DON said she called the facility and instructed them to take CNA B off the floor immediately. The DON said when she arrived at the facility, she went to check on Resident #1 to make sure she was safe and had no injuries. The DON said when she spoke with CNA B, she was told that Resident #1 was aggressive and trying to pull on the remote control for the bed. The DON said even with that behavior, no matter what, CNA B had no right to slap Resident #1. The DON said the police were called and CNA B was arrested and escorted off the property that evening on 04/29/24. The DON said all staff were in-serviced on abuse immediately and it was explained to them that any form of abuse would not be tolerated. The DON said she did watch the video that was sent by Resident #2's RP and saw that Resident #1 walked in pleasantly and sat on the end of the bed and had a conversation with CNA B. The DON said from her perspective, it appeared like Resident #1 was having a conversation with a friend. The DON said further into the conversation, after CNA B slapped her, Resident #1 stood at the door of the room waiting on her. The DON said LVN A told her that night she saw both Resident #1 and CNA B walking out of the room together holding CNA B's hand. The DON said there had never been any abuse allegations or accusations made against CNA B prior to this incident. The DON said CNA B had entered Resident #2's room to strip the bed because it was his shower day. The DON said Resident #1 was known to walk with staff often, so she assumed Resident #1 saw CNA B walk into Resident #2's room and just followed her. The DON said she and the police checked on Resident #1 three different times that evening and she had no recollection of what happened to her afterwards.
In an interview on 08/06/24 at 3:35 PM with the Administrator revealed she got a call from the nurse that Resident #2's RP told her that while he was looking at the camera, he saw CNA B slap a resident. The Administrator said she asked the nurse where CNA B was to which she told her she was right there with the nurse. The Administrator said she watched the video that was sent by Resident #2's RP and decided to drive to the facility. The Administrator said she instructed staff to send CNA B downstairs off the floor. The Administrator said when she saw Resident #1, she was not harmed and had no recollection of what happened to her. The Administrator said she gave CNA B a piece of paper to write down what happened and meanwhile she called the police. The Administrator said she started to fill out CNA B's termination paperwork and when she gave it to CNA B, CNA B was confused and refused to sign it. The Administrator said the police arrested CNA B onsite at the facility. The Administrator said she also called Resident #1's family to inform them of what happened. The Administrator said the DON began an in-service regarding abuse that evening on 04/29/24 with staff and continued until all staff had been in-serviced. The Administrator said she did watch the video, but it was hard for her to watch it. The Administrator said when she did watch the video, she saw Resident #1 sitting on the bed and CNA B was focused on making up the bed. The Administrator said she thought Resident #1 said she was going downstairs repeatedly and then somehow she got the remote to the bed and did not let go. The Administrator said CNA B whacked Resident #1 and a loud pop could be heard on the video and Resident #1 began to scream and called CNA B names. The Administrator said later on someone told her they saw Resident #1 and CNA B walking to the nurse's station to say the bed remote was not working. The Administrator said she thought there was something very wrong in CNA B's head that night. The Administrator said she remembered hearing CNA B cursing at Resident #1 which was not appropriate at all. The Administrator said Resident #1 liked to follow staff around which was probably why she followed CNA B into Resident #2's room. The Administrator said there had never been any allegations or accusations against CNA B prior to this. The Administrator said employees should never abuse residents and everyone was aware of the policy to not abuse residents since they have a right to be free from abuse.
In an interview on 08/06/24 at 1:28 PM with CNA F revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 1:44 PM with CNA G revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 2:00 PM with CNA H revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
In an interview on 08/06/24 at 2:14 PM with LVN I revealed she knew the facility's policy on abuse and knew de-escalation techniques for when a resident became agitated with them or anyone else in the facility.
Review of an in-service, dated 04/25/24, revealed CNA B and other staff had been in-serviced regarding abuse and neglect.
Review of an in-service, dated 04/29/24, revealed staff had been in-serviced regarding abuse and neglect, stress management, and de-escalation strategies.
Review of an Employee Warning Notice for CNA B, dated 04/29/24, reflected under the Violation Type section an x was next to Inappropriate Behavior, Violation of Company Policies, and Other: Abuse. Further review under the section titled Description, including date(s) of incidents was: Admits to striking a resident. Under the section Actions to be Taken (verbal warning, written warning, final warning, termination) was Current Action: Termination. At the bottom of the page was signatures from the Administrator and DON with a note that read employee refused to sign.
Apr 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of eight residents (Resident #1) reviewed for quality of care.
Resident #1, who was on aspirin, had an unwitnessed fall with head injury and a significant amount of bleeding from his head. He was transferred into the wheelchair and showered by LVN D and CNA E prior to the completion of a full assessment. Resident #1 was subsequently sent to the hospital and diagnosed with a displaced hip fracture which required surgery.
An Immediate Jeopardy (IJ) was identified on 04/25/24. While the IJ was removed on 04/26/24 at 3:30 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.
This failure could place residents at risk of impairment or serious harm.
Findings included:
Record review of Resident #1's face sheet, dated 04/26/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: alcohol-induced dementia (decline in memory, thinking, and behavior), major depressive disorder (mood disorder), pulmonary fibrosis (scarring of lungs), chronic pain, dysphasia (difficulty swallowing), and muscle weakness.
Record review of Resident #1's annual MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 2. The resident was usually understood by other and usually understood others. The resident required moderate assistance with all activities of daily living.
Record review of Resident #1's care plan, revised on 11/12/23, reflected the resident had limited physical mobility related to confusion and dementia with interventions to encourage participation in activities that promote mobility and to monitor/document/report and s/sx of immobility, contractures forming or worsening, thrombus (blood clots) formation, skin-breakdown, fall related injury. Resident #1 was high risk for falls related to confusion and dementia with interventions that included anticipating and meeting resident needs, ensuring call light was within reach, encouraging the resident to participate in activities that promote exercise/improved mobility, ensure resident had on appropriate footwear, following the facilities fall protocol, maintain a safe environment (floors free from spills, clutter, adequate light, bed in lowest position at night, handrails on walls), and provide activities that minimize the potential for falls. Further review reflected Resident #1 was on anticoagulant therapy (aspirin 81 mg daily for heart health) with interventions that included administering anticoagulant medications as ordered and monitor for side effects and effectiveness.
Record review of Resident #1's medical records, dated 04/22/24, from the local hospital reflected in part the following:
[Resident #1] presents to the hospital due to a fall with head injury .
CT scan findings included:
-no acute intracranial abnormality
-Right parietal scalp (side of head) hematoma (bruise)
-mildly impacted and displaced sub-capital right femoral neck (hip) fracture.
Hip fracture was treated with open reduction and internal fixation (surgery).
Record review of Resident #1's incident report, dated 4/22/24, and completed by LVN D reflected:
[CNA E] notified that [Resident #1] was found on the floor in his bedroom, near his roommate's bed .[Resident #1] was found on the floor on his left side. There was a puddle of blood on the floor, and it was apparent that he hit his head on the right back side of his head. Large laceration noted to the back of his head. [Resident #1] left side of his body appears to be sore by [Resident #1] saying 'ouch'. Assessment completed, no changes or abnormalities noted in extremities. [Resident #1] was transferred from floor to wheelchair and taken to shower room to be cleaned up.
Record review of Resident #1's progress note by LVN D, dated 4/23/22 at 12:09 AM, reflected:
[LVN D]: Writer was notified by [CNA E] that [Resident #1] was on the floor upon her entering the bedroom. Nurse went to assess and observe that resident was on the floor on his left side. There was a puddle of blood on the floor, and it was apparent that he hit his head on the back right side of his head. Large laceration noted to the back of his head. Resident's left side of body appears to be sore by hearing the resident saying 'ouch'. Resident was picked up by writer and [CNA E] and placed in wheelchair. We then took him to the shower room to get him cleaned up and to further assess him. No other bleeding from current fall noted. On-call for MD was contacted, and a message was left of findings and that he would be transferred to [local hospital] due to him hitting his head. [RP] was phoned twice with no answer. [family member] was phoned twice with no answer .
In an observation on 04/25/24 at 10:25 AM, Resident #1 was sitting in the dining area with staff and other residents. Resident #1 could not be interviewed due to cognition. Resident #1did not have any visible marks/bruises other than the laceration to the right side of his head.
In an interview on 04/25/24 at 9:30 AM, the DON stated it was reported to her that staff were assisting the resident to bed and doing rounds when Resident #1 was found on the floor. The DON stated Resident #1 was transferred to the hospital where it was found that his right hip was fractured, and he had to undergo a closed surgical procedure for treatment. The DON stated she asked LVN D to describe the position Resident #1 was lying in so she could get an idea of how the fall occurred and it was reported Resident #1 was lying near his roommate's bed with his feet towards the door. The DON stated LVN D reported Resident #1 was lying in a pool of blood coming from behind his head, with no other injuries observed. The DON stated LVN D reported Resident #1 grabbed his left side and said ouch but till did not show signs his hip was fractured. The DON stated sometimes residents with dementia don't feel pain due to pain transmitters not functioning. She stated LVN D reported Resident #1 was able to stand and be transferred into a wheelchair to be taken to the shower room and cleaned up. The DON stated the resident was a fall risk but was ambulatory and had not had any recent falls.
In an interview on 04/25/24 at 12:04 PM, LVN D stated she worked for the facility for 1 year. She stated she worked overnight with Resident #1 on 4/22/24 when he had a fall. LVN D stated CNA E put Resident #1 to bed for the night and when she went back to assist his roommate, she found Resident #1 on the floor. LVN D stated CNA E notified her, and she went to the room to assess Resident #1. LVN D stated when she got in the room, she saw a lot of blood that appeared to be coming from the back right side Resident #1's head. LVN D stated there was so much blood it scared her. LVN D stated Resident #1 took aspirin which might have caused the excessive bleeding. LVN D stated she asked Resident #1 if she and CNA E could pick him up and he replied yes. LVN D stated Resident #1 did not bear any weight on his legs while she and CNA E lifted him into a wheelchair. LVN D stated Resident #1 was covered in blood, and she felt she needed to strip his clothing and clean him off to do a thorough assessment. LVN D stated before removing Resident #1 from the floor, the only assessing she did was taking his vitals, which were normal. LVN D stated she was unable to do any further assessing due to the excessive blood, so Resident #1 was then taken to the shower room to be cleaned off. LVN D stated once Resident #1 was cleaned off, there were no other injuries noted besides a laceration to the back of his head. LVN D stated Resident #1 remained responsive and was talking at his normal baseline, which was confused. LVN D stated she notified the MD and sent Resident #1 out to the local hospital. LVN D stated Resident #1 did not indicate being in any pain until the EMTs transferred him from the wheelchair onto the stretcher and he said ouch. When asked if a resident was supposed to be moved without a full assessment if there was an obvious head injury, LVN D paused then stated, You're right, I should not have moved him. LVN D stated she should have called someone before moving Resident #1 and allowed the EMTs to move him in case of unknown head/neck injuries. LVN D stated she was so shocked by all the blood and must have forgotten protocol in the moment, which was to not move the resident and call emergency services and MD.
In an interview on 04/25/24 at 12:24 PM, CNA E stated she worked at the facility for almost 2 years. She stated she worked with Resident #1 on 4/22/24 when he had a fall with a head injury. CNA E stated she was assisting Resident #1 and his roommate to bed, then she had to step out for a second to grab an extra pillow and when she returned, she found Resident #1 on the floor. CNA E stated Resident #1's bed was in the lowest position, and he was fine when she left him, so she was unsure of how he fell. She stated Resident #1 got out of bed on his own and wandered often. CNA E stated she immediately notified LVN D. CNA E stated LVN D came into the room and tried to assess Resident #1 while he was on the floor but there was too much blood for her to see properly, so she told CNA E to grab a wheelchair for them to place Resident #1 in. CNA E stated LVN D took Resident #1's vitals once they got him in the wheelchair, then they took him to the shower room to clean him off so LVN D could assess him. CNA E stated Resident #1 was still acting like himself and talking while they were moving him. She stated Resident #1 did not indicate being in any pain initially and was even able to stand and help them transfer him into the wheelchair. CNA E stated LVN D got Resident #1 cleaned up and saw the wound to the back of his head and stated he needed to be sent out to the hospital. CNA E stated EMTs arrived shortly after LVN D notified the MD and when EMTs were putting Resident #1 on the stretcher he yelled ouch.
An attempted interview on 04/25/24 at 12:51 PM with Resident #1's RP was unsuccessful due to no response to phone call.
In an interview on 04/25/24 at 1:04 PM, ADON A stated she worked at the facility since September 2022. ADON A stated at the start of her shift on 04/23/24, she checked incidents and found Resident #1 had a fall with a laceration to his head and was sent out to the hospital. ADON A stated she spoke with LVN D, and she reported Resident #1 had a fall, he was assessed, and sent out to the local hospital. ADON A stated LVN D did not report that she was unable to complete an assessment on Resident #1 before moving him. ADON A stated staff were in-serviced very frequently on fall protocols, and the trainings included proper assessments and notification. ADON A stated a proper assessment for an unwitnessed fall or a fall with an obvious head injury would be to do neurological checks, check head-to-toes for injuries, and assess for pain before moving to prevent further injury if any. ADON A stated if a nurse was unable to complete an assessment, they would be expected to leave the resident on the floor and call another nurse or the MD for further instructions.
In an interview on 04/25/24 at 4:15 PM, the DON stated LVN D reported following fall protocols by assessing Resident #1 before moving him into the wheelchair. The DON stated LVN D did not report she was unable to complete an assessment on Resident #1, otherwise, corrective action would have been taken then. The DON stated the protocol for an unwitnessed fall with an injury was to assess the resident head-to toe before moving him/her, check for obvious injuries, complete neurological checks including assessing eyes for alertness and focus. The DON stated the risk of not completing an assessment before moving a resident after an unwitnessed fall or a fall with an injury could be causing further harm to the resident.
Record review of the facility's policy titled Assessing Falls and their Causes revised March 2018 reflected in part the following:
Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.
.
Steps in the procedure
After a fall:
1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.
2. Obtain and record vital signs as soon as it is safe to do so.
3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.
4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details.
5. Notify the resident's attending physician and family in an appropriate time frame.
a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone
This was determined to be an Immediate Jeopardy (IJ) on 04/25/24 at 4:20 PM.
The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/25/24 at 5:39 PM.
The following Plan of Removal submitted by the facility was accepted on 04/26/24 at 11:30 AM:
Date: 4/25/24
Plan of Removal
For
Immediate Jeopardy
[Nursing Facility]
To Whom it may concern,
Summary of Details which lead to outcomes:
On 4/25/24, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health.
The notification of the alleged immediate jeopardy states as follows:
F 684 Quality of Care:
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who had sustained a head injury from a fall and was moved by the nurse without proper assessment.
Corrective actions for those found to have been affected by the deficient practice:
All residents have the potential to be affected. Identified resident returned to the facility with no adverse outcomes. The facility census on 4/25/24 was 89.
The identified licensed nurse will be suspended (with possible termination with HR approval) and the nurse license will be referred to the Texas Board of nursing.
Resident head to toe competencies will be completed for all licensed nurses by the end of day on 4/26/24. The following in services will be completed by 4/25/24 by the following nursing staff from the following administrative staff [DON], [ADON A], [ADON B], and [ADON C].
All current nursing staff (Nurses and CNAs), agency staff, new hires, and/or PRN Nurses and CNAs that work in the facility will have in servicing completed by end of day 4/26/24 and all other nursing staff to include nurses and CNAs that are out on leave, vacations, etc ., agency staff, new hires and/or PRN nurses and CNAs prior to working the floor by the DON/Designee.
The training provided will be the following:
Head to toe assessments - how and when to complete the assessment. Staff will understand initial assessments to rule out injury must be completed prior to moving a resident. For all unwitnessed falls and obvious head injury, neurological assessment must be completed in addition to head-to-toe assessment prior to change in position.
Significant changes in status - when a resident has a change who to report it to
Incidents and accidents and how to report and complete.
Reporting to the physicians - reporting any significant changes or incident that occur with a resident and in a timely manner.
Reporting to the administrative staff - any significant changes or incidents that has been reported, observed, or noted.
Abuse and neglect - who to report to, types of abuse, prevention strategies.
Fall management - intervention to put in place and what to do when a fall occurs.
suspected injury or unwitnessed fall by the staff member while the resident is not in the facility - if/when the nurse is made aware of the alleged incident the physician will be notified, incident report completed, and assessment will be completed.
Agency staff, new hires, and/or PRN Nurses and CNA's that work in the facility will have in servicing completed prior to working the floor by the DON/Designee.
Ongoing monitoring:
All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved.
An Emergency QAPI meeting was conducted on 4/25/24. The Medical Director was notified and agrees with the plan.
Current and past falls for the last 30 days will be reviewed for compliance to ensure that regulatory guidelines have been met.
Who is responsible for implementing of processes?
The administrative nurses (ADON and DON) and Administrator.
Monitoring of the POR included the following:
Interviews on 04/23/24 between 12:45 PM-3:10 PM were conducted with the DON, ADON A, RN F (7:00 AM-7:00 PM shift), LVN G (7:00 PM-7:00 AM shift), CNA H (7:00 AM-7:00 PM shift), LVN I (7:00 AM-7:00 PM shift), CNA J (7:00 AM-7:00 PM shift), LVN K (7:00 AM-7:00 PM shift), CNA L (7:00 AM-7:00 PM shift), CNA M (7:00 PM-7:00 AM shift), CNA N (7:00 PM-7:00 AM shift), LVN O (7:00 PM-7:00 AM shift) and LVN P (7:00 PM-7:00 AM). All nurses were able to provide competency regarding in-services regarding protocol for unwitnessed falls and falls with obvious injuries. The nurses stated after an unwitnessed fall or fall with injury, they would complete a head-to-toe assessment of the resident before moving them, then assist the residents to a comfortable position only after injuries were ruled out. The nurses stated if the assessment determined the resident had a serious injury and could not be moved or if the assessment was notable to be completed for any reason, the MD and/or emergency services would be notified immediately, and appropriate documentation would be completed. The aides stated if a resident had an unwitnessed fall or a fall with an injury, they would leave the resident in the position they were found in and immediately notify the nurse for the resident to be assessed.
Record review of Residents #1, #2, #3, #4, #5, #6, #7 and #8 who were all at risk for falls, electronic health records reflected interventions were in place for fall prevention and fall protocols were followed appropriately for any documented falls.
Record review of in-services on 04/25/24-04/26/24, conducted by the DON, reflected all staff were trained during or prior to their shift on fall protocols which included assessing the resident, monitoring for significant changes in status, reporting to the physician/family, and completing incident reports.
Record review of a document provided by the DON reflected an audit of resident falls from the past 30 days to ensure compliance was started.
Record review of the QAPI sign-in sheet, dated 04/25/24, provided by the Administrator reflected the QAPI committee was notified of the identified immediate jeopardy and interventions were implemented.
The Administrator and the DON were informed the Immediate Jeopardy was removed on 04/26/24 at 3:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential or more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
Apr 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0635
(Tag F0635)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure at the time residents were admitted they had physician order...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure at the time residents were admitted they had physician orders for the resident's immediate care for 1 (Resident #74) of 5 residents reviewed for admission orders.
The facility failed to enter physician's orders for Resident #74's hospice and catheter care.
This failure could cause the residents to have incomplete care with hospice and improper incontinent care and urinary tract infections.
Findings included:
Review of Resident #74's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Dementia, Type 2 Diabetes (high blood sugar), Hypothyroidism (lack of thyroid hormones), Hypertension (high blood pressure).
Review of Resident #74's MDS, dated [DATE], revealed Resident #74 had a BIMS of 14 indicating cognition was intact. Resident #74 required use of indwelling suprapubic catheter. The MDS did not indicate Resident #74 entered the facility on hospice or was on hospice during his stay.
Review of Resident #74's baseline care plan, dated 02/27/24, indicated Resident #74 was admitted with a suprapubic catheter due to incontinence of the bladder, and there was no mention of the resident being on hospice care.
Review of Resident #74's interim care plan dated 02/28/24 indicated No to him having a catheter and Yes to him having hospice/end of Life care.
Review of Resident #74's progress notes dated 02/27/24 at 7:33 PM revealed Resident #74 arrived to the facility with a family member from hospital. Resident #74 would be admitted to hospice per hospital. Resident #74's assessment revealed he was not ambulatory and had a suprapubic catheter in use since September 2024, incontinent of bowel.
Review of Resident #74's orders on 04/16/23 revealed orders dated 03/25/24 revealed an order to secure tubing with anchor and check placement every shift two times a day for suprapubic catheter. Resident #74's orders also revealed there was no order for hospice care.
Record review of a list provided by the facility on 04/16/24 of residents on hospice revealed Resident #74 was not included.
Observation of Resident #74 on 04/17/24 at 10:06 AM revealed staff were completing incontinent care.
Interview on 04/17/24 at 4:20 PM with LVN C revealed Resident #74 entered the facility a couple of months ago, February or early March 2024. According to LVN C Resident #74 entered the facility with hospice care and with the use of a suprapubic catheter. LVN C stated she had not noticed whether there was an order for Resident #74 regarding his hospice or catheter care. According to LVN C the admitting nurse was responsible for entering orders upon admission. LVN C stated there was no risk involved for Resident #74's care with hospice or his catheter because he was seen by the hospice aide 5 days a week, nurse 1-2 days a week. LVN C stated they could observe Resident #74 with catheter therefore provided care for it. LVN C stated physician and nurse practitioners were in the building constantly and did rounds with Resident #74 and could provide care instructions if needed.
Interview on 04/17/24 at 4:54 PM with the ADON, ADON reviewed her list of hospice residents and stated Resident #74 was not on hospice. Upon further review, the ADON stated after speaking with staff Resident #74 was in fact on hospice and his order was missed by the admitting nurse. The ADON stated it was the admitting nurse's responsibility to receive all orders and enter them. The ADON stated it was the responsibility of the ADON and DON to review all new orders. The ADON stated Resident #74 was not at risk because he had not missed any care.
Interview on 04/17/24 at 5:30 PM with the DON revealed the admitting nurse was responsible for entering all orders from the hospital discharge paperwork. The DON stated the admitting nurse would enter and verify orders, enter any monitoring, appointment follow ups and triggers. The admitting nurse would then notify the physician of any changes or new orders needed. The DON stated ADONs were responsible for reviewing new orders daily. According to the DON, Resident #74's hospice orders were missed by the admitting nurse and the ADON's review. The DON stated Resident#74's catheter orders were completed later after discovering the orders were not entered. The DON stated admitting orders should have been entered immediately after admission to provide proper care and needs of the residents.
Record review of catheter orders 04/18/24 12:00 PM revealed catheter orders were present.
Review of facility policy titled admission Notes reflected:
.Preliminary information shall be documented upon a resident's admission to the facility.
When a resident is admitted to the nursing unit, the admitting nurse must document the following information .
Reason for admission
The admitting diagnosis
The time the physician's orders were received and verified.
The presence of a catheter, dressings, etc
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and review the care plan for 1 of 5 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and review the care plan for 1 of 5 residents (Resident #74) reviewed accuracy of assessments.
The facility failed to indicate on Resident #74's Minimum Data Set that he entered the facility on Hospice care.
These failures could lead to the residents not receiving the care they require, resulting in injuries.
Findings included:
Review of Resident #74's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Dementia, Type 2 Diabetes (high blood sugar), Hypothyroidism (lack of thyroid hormones), Hypertension (high blood pressure).
Review of Resident #74's MDS dated [DATE], revealed Resident #74 had a BIMS of 14 indicating cognition was intact. MDS did not indicate Resident #74 entered the facility on Hospice or was on Hospice during his stay.
Review of Resident #74's baseline care plan, dated 02/27/24, indicated Resident #74 was admitted with no mention of resident on Hospice care.
Review of Resident #74's interim care plan dated 02/28/24 indicated Yes to him having Hospice/End of Live Care.
Review of Resident #74's updated comprehensive care plan revealed hospice services were entered on 03/26/24. Goal: Resident will be kept comfortable and will receive support from hospice team including nursing care, activities of daily living assistance, social services, and spiritual services. Resident will have adequate pain control and all optimum comfort measures in place. Interventions: 11th hour referral: If available at the time Resident #74 becomes imminent, services will be provided by facility to ensure he is not alone during last hours of life. Coordinate care with hospice company and notify hospice for any change in condition, unmet need requiring hospice intervention, requests from family.
Observation of Resident #74 on 04/17/24 10:06 AM revealed staff were completing incontinent care.
An attempt to contact the admitting nurse revealed the interview unsuccessful.
Interviewed on 04/17/24 at 4:20 PM with LVN C revealed Resident #74 entered the facility a couple of months ago, February or early March 2024. According to LVN C Resident #74 entered the facility with hospice care. LVN C stated she had not noticed whether there was an order for Resident #74 regarding his hospice. According to LVN C the admitting nurse was responsible for entering orders upon admission. LVN C stated there was no risk involved for Resident #74's care with hospice or his catheter because he was seen by the hospice aide 5 days a week, nurse 1-2 days a week.
Interviewed on 04/17/24 at 4:54 PM with the ADON revealed she was the MDS Coordinator. The ADON stated she was not aware Resident #74's care plan did not show hospice on his MDS assessment. The ADON stated once a resident admits to the facility the orders for care are entered by admitting nurse. She stated once the order was entered the resident's MDS would then be triggered. The ADON stated she was responsible for ensuring resident MDS assessments were accurate and completed.
Interviewed on 04/17/24 at 5:30 PM with the DON revealed the admitting nurse was responsible for entering all orders from the hospital discharge paperwork. The DON stated the admitting nurse would enter and verify orders, enter any monitoring, appointment follow ups and triggers. The DON stated an assessment was completed upon admission creating the baseline care plan. The DON stated 21 days later an interdisciplinary team met to enter areas for care for the comprehensive care plan. The DON stated the MDS Coordinator was the last to review care plan and make any updates or changes to ensure proper care will be provided to the resident. DON stated the MDS Coordinator was responsible for ensuring resident's MDS assessments were accurate.
Interviewed on 04/18/24 at 3:10 PM with the Social Worker revealed she was working with Resident #74 and his family after his admission and realized Resident #74's care plan did not include care for hospice. The Social Worker stated she knew that he was on hospice care and that it needed to be documented. The Social Worker stated it was about a month later that she updated the care plan to reflect that Resident #74 was on hospice. The Social Worker stated she was not responsible for updating the care plan but thought it was appropriate to include his care for hospice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and review the care plan for 2 of 5 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and review the care plan for 2 of 5 residents (Residents #2 and #74) reviewed for comprehensive care plans.
1. The facility failed to ensure Resident # 2's care plan after he was unable to use the call light system to call for help.
2. The facility failed to revise and review Resident #74's care plan after admission to include Hospice in a timely manner.
3. The facility failed to revise and review Resident #74's use of suprapubic catheter.
These failures could lead to the residents not receiving the care they require, resulting in injuries.
Findings included:
Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, muscle weakness, and repeated falls.
Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he was severely cognitively impaired. His Functional Status indicted he required a wheelchair for mobility, and he required substantial assistance with all his ADLs. Resident #2 was also always incontinent of bowel and bladder. Resident #2's Pain Assessment indicated he had no chronic pain.
Review of Resident #2's care plan, dated 04/17/24, revealed he had quarter bed rails for safety and repositioning, he required assistance with meeting physical needs due to dementia, he suffered from insomnia, he only came out of his room for meals, and he had mobility issue s related to contractures of his legs.
Review of Resident #2's EHR revealed his Morse Fall Scale scores indicated he was a high fall risk since he was admitted . Resident #2 also suffered falls on:
11/8/22 - no injuries
11/29/22- no injury
12/3/22- no injury
1/10/23- no injury
1/28/23- no injury
3/2/23- no injury
4/9/23- no injury
4/25/23 - no injury
9/08/23- no injury
9/17/23- no injury
10/24/23-unwitnessed fall, no injury
12/3/23-unwitnessed fall
1/31/24 - witnessed fall - no injury.
Observation and interview on 04/16/24 at 11:26 AM revealed Resident #2 was on his left side in bed. Resident #2's call light button was located on the bedrail behind him. Resident #2 was asked how he called for help when he needed it and he pointed at the ceiling. The resident's call light was moved to the bedrail in front of him and he was asked to call for help. The resident pointed to the surveyor's watch. Resident #2's bed was in the low position, and he had fall mats on both sides of his bed.
Interview on 04/17/24 at 1:36 PM with CNA A revealed Resident #2 did not know how to use his call light, even when it was placed in his hand. CNA A stated she checked on Resident #2 every two hours as he spent almost all his time in his bed. CNA A stated she had not witnessed any falls by Resident #2, but understood he was usually found on the floor beside his bed except his last fall (03/21/24) happened in the hallway when he fell out of his wheelchair. CNA A stated Resident #2 had been unable to use his call light for at least three months.
Interview on 04/17/24 at 1:42 PM with LVN B revealed Resident #2 only came out of his room for meals, and occasionally to watch a movie on television. Staff knew he was a fall risk and would check on him every two hours. LVN B agreed that Resident #2 was not able to use his call light to request help. LVN B stated resident care plans were updated by the Care Plan Coordinator.
Review of Resident #74's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Dementia, Type 2 Diabetes (high blood sugar), Hypothyroidism (lack of thyroid hormones), Hypertension (high blood pressure).
Review of Resident #74's MDS, dated [DATE], revealed Resident #74 had a BIMS of 14 indicating cognition was intact. MDS indicated Resident #74 required use of indwelling suprapubic catheter. MDS did not indicate Resident #74 entered the facility on Hospice or was on Hospice during his stay.
Review of Resident #74's baseline care plan, dated 02/27/24, indicated Resident #74 was admitted with Suprapubic Catheter due to incontinent of the bladder, no mention of resident on Hospice care.
Review of Resident #74's interim care plan dated 02/28/24 indicated No to him having a catheter and Yes to him having Hospice/End of Live Care.
Review of Resident #74's updated comprehensive care plan revealed hospice services were entered on 03/26/24. Goal: Resident will be kept comfortable and will receive support from hospice team including nursing care, activities of daily living assistance, social services, and spiritual services. Resident will have adequate pain control and all optimum comfort measures in place. Interventions: 11th hour referral: If available at the time Resident #74 becomes imminent, services will be provided by facility to ensure he is not alone during last hours of life. Coordinate care with hospice company and notify hospice for any change in condition, unmet need requiring hospice intervention, requests from family. Resident #74's care plan did not reflect his use of a suprapubic catheter.
Observation of Resident #74 on 04/17/24 at 10:06 AM revealed staff were completing incontinent care.
An attempt to contact the admitting nurse revealed the interview unsuccessful.
Interview on 04/17/24 at 4:20 PM with LVN C revealed Resident #74 entered the facility a couple of months ago, February or early March 2024. According to LVN C Resident #74 entered the facility with hospice care and with the use of a suprapubic catheter. LVN C stated she had not noticed whether there was an order for Resident #74 regarding his hospice or catheter care. According to LVN C, the admitting nurse was responsible for entering orders upon admission. LVN C stated there was no risk involved for Resident #74's care with hospice or his catheter because he was seen by the hospice aide 5 days a week, nurse 1-2 days a week. LVN C stated they could observe Resident #74 with catheter therefore provided care for it. LVN C stated physician and nurse practitioners were in the building constantly and did rounds with Resident #74 and could provide care instructions if needed.
Interview on 04/17/24 at 4:54 PM with the ADON revealed she was the MDS Coordinator. The ADON stated she was not aware Resident #74's care plan did not show hospice or with use of a catheter on his care plan. The ADON stated once a resident admits to the facility the orders for care are entered by admitting nurse. She stated once the order was entered the resident's MDS and care plans are then triggered. The ADON stated care plans were updated by outside staff, by a third party.
Interview on 04/17/24 at 5:30 PM with the DON revealed the admitting nurse was responsible for entering all orders from the hospital discharge paperwork. The DON stated the admitting nurse would enter and verify orders, enter any monitoring, appointment follow ups and triggers. The DON stated an assessment was completed upon admission creating the baseline care plan. The DON stated 21 days later an interdisciplinary team met to enter areas for care for the comprehensive care plan. The DON stated the MDS Coordinator was the last to review care plan and make any updates or changes to ensure proper care will be provided to the resident.
Interview on 04/18/24 at 3:10 PM with the Social Worker revealed she was working with Resident #74 and his family after his admission and realized Resident #74's care plan did not include care for hospice. The Social Worker stated she knew that he was on hospice care and that it needed to be documented. The Social Worker stated it was about a month later that she updated the care plan to reflect that Resident #74 was on hospice. The Social Worker stated she was not responsible for updating the care plan but thought it was appropriate to include his care for hospice.
Interview on 04/18/24 at 1:24 PM with the Care Plan Coordinator revealed she was responsible for updates to resident care plans as she gets the information, usually at their morning meetings. She stated it was important to keep the care plans up to date to ensure residents received the appropriate care. The Care Plan Coordinator stated she knew of other residents that were care planned for inability to use the call light to summon help. The Care Plan Coordinator stated residents having a way to ask for help, use of catheter, and hospice care included on the care plan was important to prevent risk of diminished way of life.
Review of the facility's policy Care Plans, dated April 2009, reflected:
.3.
Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and:
a.
is resident oriented.
b.
is behaviorally stated.
c.
is measurable; and
d.
contains timetables to meet the resident's needs .
4. Goals and objective are entered on the resident's care plan so that all disciplines have access to such information and can report whether the desired outcomes are being achieved .
5. Goals and objectives are reviewed and/or revised:
a. when there has been a significant change in the resident's condition .
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident environment remained free of accidents hazards ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents hazards.
The facility failed to ensure that Resident #1 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer.
This failure could place residents at risk of falls or injuries.
Findings included:
Review of Resident #1's electronic face sheet dated 02/21/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities), Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and hypertension (high blood pressure).
Review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 had a BIMS of 01 which indicated severe cognitive impairment. Review of section GG titled functional abilities and goals indicated Resident #1 required two person assist for transfer from chair to bed.
Review of Resident #1's care plan revised 03/16/2022 indicated focus areas included the following: Resident #1 had an ADL Self Care Performance Deficit. interventions included to TRANSFER: The resident requires mechanical Hoyer lift with two staff for assistance.
Review of camera footage dated 02/12/2024 at 7:29 AM provided by Family A revealed CNA B had Resident #1 on the sling and hooked the sling up to the mechanical Hoyer lift. CNA B proceeded to lift Resident #1 off the bed and attempt to position him to transfer him to the wheelchair without assistance of another CNA. CNA B lifted Resident #1 from over the bed then put him back over the bed and left him hanging in the air while she went to get assistance.
Observation on 02/21/2024 at 10:50 AM, Resident #1 was in his bed in the lowest position with a mat on the floor. Resident #1 was not able to complete an interview due to cognitive impairment.
Interview on 02/21/2024 at 10:53 AM, CNA C stated she did assist CNA B with transferring; however, she was not sure if CNA B had attempted to transfer Resident #1 before she arrived to the room. CNA C stated transfers using mechanical Hoyer lifts should be done with two people.
Interview on 02/21/2024 at 2:45 PM, CNA B stated she was trying to determine if the Hoyer lift was working properly or not which was why she was moving the resident in the lift. CNA B stated residents should have been transferred using a Hoyer lift with two people. CNA B stated the risk of transferring a resident with one-person would-be injury. CNA B stated she had completed Hoyer lift training when she was hired; however, she was not sure if she had it again.
Interview on 02/21/24 at 3:00 PM, the Director of Nursing revealed therapy completed most trainings regarding transfers. The Director of Nursing stated the education department was responsible for keeping track of when staff were due for training. The Director of Nursing stated she was not aware of CNA B attempting to transfer Resident #1 alone. The Director of Nursing stated staff were trained to always have two people for transferring residents with Hoyer lift. The Director of Nursing stated the risk of transferring a resident alone using a Hoyer lift would be possible injury to the staff member as well as the resident. The Director of Nursing stated Caregiver B would be suspended and retrained regarding transfers.
Review of the facility policy Safe lifting and movement of residents revised 2017 revealed, Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of four residents reviewed for discharge.
The facility failed to notify Resident #1, the resident representative, and the Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal.
This failure could put residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.
Findings included:
Review of Resident #1's facesheet provided 04/27/23 revealed the resident was admitted to the facility on [DATE]. His diagnoses included post traumatic stress disorder, narcissistic personality disorder, major depressive disorder, anxiety disorder, and pain.
Review of Resident #1's nurses noted dated 03/27/23 reflected the following:
8:08 AM - This LVN was on the unit at time of incident, noted staff running out of room stating he was trying to choke her, he had her hands around her throat and had pushed her against the wall
1:16 PM - Referral for Med Management with [behavioral health services] completed today. Telehealth appointment done today with [PNP] recommending inpatient treatment.
5:04 PM - Report was called to VA ER via [transport] and VA is expecting wife to accompany resident left to go to VA ER at this time, wife did not take any clothes or personal belongings.
Interview on 04/27/23 at 3:45 PM with the Social Worker revealed psych services were set up for Resident #1 because he was having behaviors such as assaulting staff. The Social Worker stated the behavioral health services said Resident #1 needed to be sent out for inpatient treatment due to being a danger to himself and others. The Social Worker said the Administrator was the one who handled Resident's #1's discharge.
Interview on 04/27/23 at 4:49 PM with the DON revealed Resident #1 was discharged to the VA ER after a telehealth call with the behavioral health services recommended he be sent out due to being a danger to himself and others. The DON stated Resident's family refused for the resident to be sent via ambulance and they opted to drive him themselves. The DON said they had initially planned for the resident to return to the facility if the hospital could get Resident #1 stabilized.
Interview on 04/27/23 at 5:43 PM with the Administrator revealed Resident #1 was sent out the hospital for aggressive behaviors. The Administrator said she did not issue a discharge notice because in her opinion Resident #1 was being sent to a hospital; therefore, the resident would not have required a discharge notice.
Interview on 04/27/23 at 4:33 PM with the Ombudsman revealed she began to be included in email chains between the facility staff and Resident #1's family after the resident had been discharged to the hospital. She further stated she had not received a formal discharge notice for Resident #1, and her only involvement had been her reading the email chain.
Review of the facility's policy titled Discharging the Resident revised in 2016 reflected it did not address the transfer notice to include reasons for the move or sending a copy to the Ombudsman.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 7 life-threatening violation(s), 1 harm violation(s), $71,321 in fines, Payment denial on record. Review inspection reports carefully.
- • 18 deficiencies on record, including 7 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $71,321 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is James L West Center For Dementia Care's CMS Rating?
CMS assigns James L West Center for Dementia Care an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is James L West Center For Dementia Care Staffed?
CMS rates James L West Center for Dementia Care's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 46%, compared to the Texas average of 46%.
What Have Inspectors Found at James L West Center For Dementia Care?
State health inspectors documented 18 deficiencies at James L West Center for Dementia Care during 2023 to 2025. These included: 7 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 10 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates James L West Center For Dementia Care?
James L West Center for Dementia Care is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 112 certified beds and approximately 100 residents (about 89% occupancy), it is a mid-sized facility located in Fort Worth, Texas.
How Does James L West Center For Dementia Care Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, James L West Center for Dementia Care's overall rating (2 stars) is below the state average of 2.8, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting James L West Center For Dementia Care?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is James L West Center For Dementia Care Safe?
Based on CMS inspection data, James L West Center for Dementia Care has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 7 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at James L West Center For Dementia Care Stick Around?
James L West Center for Dementia Care has a staff turnover rate of 46%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was James L West Center For Dementia Care Ever Fined?
James L West Center for Dementia Care has been fined $71,321 across 9 penalty actions. This is above the Texas average of $33,792. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is James L West Center For Dementia Care on Any Federal Watch List?
James L West Center for Dementia Care is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.