Health inspection·September 5, 2025

483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented On 7/24/25 at 11:00 a.m., an unannounced visit was conducted at the facility to investigate a Facility Reported Incident survey regarding an allegation of resident abuse. Resident 1 was a 90-year-old female resident, admitted to the facility on 1/2/24. Resident 1 had diagnoses that included Alzheimer's disease (a progressive neurological disorder that causes brain cells to degenerate [a gradual worsening or deterioration of the function or structure of cells, tissues, or organs over time, leading to a lower or less effective state], leading to memory loss, cognitive decline, and impaired daily functioning), Delusional disorders (a mental illness characterized by persistent, non-bizarre delusions lasting at least one month, without other symptoms of psychosis [a mental health condition characterized by a loss of contact with reality] and Bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, alternating between periods of elevated mood and periods of depression). Resident 1 was oriented to self only with BIMS score of 3 out of 15, which indicates severe cognitive impairment. Resident 1 was ambulatory with a history of wandering and required redirecting. The facility failed to: 1. Ensure Resident 1 was free from physical and verbal abuse when on 7/17/25, Certified Nursing Assistant (CNA) 1 was witnessed grabbing Residents 1's left arm forcefully and escorting Resident 1 back to her room. CNA 1 was witnessed saying to Resident 1, "You're starting already, this needs to stop," and "You're always doing this, you need to stay in your room." Resident 1 was then instructed by CNA 1 to remain in her room with the door closed. 2. Ensure the facility's policies and procedures (P&P) titled, "Resident Rights" and "Abuse Prevention Program," were implemented and followed. These failures resulted in the violation of Resident 1's right to a dignified existence, to be treated with respect and care in a manner and in an environment that promotes maintenance or enhancement of her quality of life according to the facility's P&P. During a concurrent observation and interview on 7/24/25 at 10:53 a.m. with Resident 1, Resident 1 was sitting on a chair in the lobby with a staff member. Resident 1 was pleasant, easily redirected, compliant and cooperative. The Registered Nurse Supervisor (RNS) escorted Resident 1 to her room for an interview. Resident 1 had a wander guard (a device designed to automatically alarm to prevent residents from leaving a designated safe area) on her left ankle. Resident 1 was Spanish speaking only and the RNS interpreted. Resident 1 was oriented (aware) of self only and answered simple questions. Resident 1 was unable to recall the incident on 7/17/25. Resident 1 stated staff treated her well and stated she felt safe. During a record review of Resident 1's "Admission Record," dated 7/17/25, the AR indicated, Resident 1 was admitted on 1/25/24 with a history of Alzheimer's disease (a progressive neurological disorder that causes brain cells to degenerate [a gradual worsening or deterioration of the function or structure of cells, tissues, or organs over time, leading to a lower or less effective state], leading to memory loss, cognitive decline, and impaired daily functioning), Delusional disorders (a mental illness characterized by persistent, non-bizarre delusions lasting at least one month, without other symptoms of psychosis [a mental health condition characterized by a loss of contact with reality] and Bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, alternating between periods of elevated mood and periods of depression). During a review of Resident 1's "Brief Interview for Mental Status (BIMS- an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life)," dated 7/1/25, the BIMS score indicated Resident 1 was severely cognitively impaired (scores below 7) with a score of 3 out of 15, where a score between 13-15 indicates cognitively intact. During a record review of Resident 1's "Post-Event Review (PER)," dated 7/17/25, the PER indicated, "... 5. IDT [Interdisciplinary Team - a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff] Review: IDT met to review incident that occurred 07/17/2025. Per staff, they witnessed the CNA assigned to [Resident 1] grab her arm aggressively to pull her back into her room. Upon witnessing this, the CNA assigned was sent home immediately and suspended pending investigation. Upon investigation, it was determined that he did grab her in an aggressive manner and staff member will be terminated and not allowed back to work. [Resident 1] is not able to recall incident due to her [diagnosis] dementia (a medical condition characterized by a progressive decline in cognitive abilities, such as memory, thinking, language, and judgment, that interferes with daily functioning and social interactions). Body assessment was completed and no injuries noted. [Resident 1] continues to get up daily and ambulate around the facility per her normal routine. She was pleasant during interview. No signs of emotional distress noted. Staff will continue to monitor and address any changes if they occur..." During a review of Resident 1's "Care Plan Report (CPR)," dated 7/6/25, the CPR indicated, "The resident has impaired cognitive function/dementia or impaired thought processes [related to (r/t)] Alzheimer's, Dementia; Constantly pacing/wandering with no purpose... Interventions: Engage the resident in simple, structured activities that avoid overly demanding tasks... Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion..." During a review of Resident 1's "CPR," dated 7/17/25, the CPR indicated, "Resident allegedly received physical aggression to her left arm from a staff member on 7/17/25... Interventions: Monitor for emotional distress [every (Q)] shift [times (x)] 72 [hours (H)]. Monitor left upper arm for any redness, pain, swelling, or new skin discoloration x 72H. Notify [Medical Doctor (MD)] of any changes with resident." During an interview on 7/24/25 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/17/25 she and CNA 3 witnessed CNA 1 grab Resident 1's left arm in the hallway and escorted Resident 1 back to her room. LVN 1 stated CNA 1 was "forceful and agitated" with Resident 1. LVN 1 stated CNA 3 informed the Administrator (ADM) immediately and the ADM instructed CNA 1 to leave the facility. LVN 1 stated Resident 1 was assessed with no physical or psychosocial harm. LVN 1 stated Resident 1 was ambulatory (able to walk without assistance) and had dementia. LVN 1 stated Resident 1 liked to wander in the facility and required redirecting. LVN 1 stated if a staff member was unable to redirect a resident, then the staff member was required to request other staff members for assistance. LVN 1 stated staff need to treat all residents with care and compassion. LVN 1 stated CNA 1 did not treat Resident 1 with dignity and respect during the incident. During an interview on 7/24/25 at 11:15 a.m. with CNA 2, CNA 2 stated she was currently assigned to Resident 1. CNA 2 stated Resident 1 had a history of dementia, was sweet and required assistance with activities of daily living (ADL- such as dressing, toileting, washing, feeding, mobility, and transferring). CNA 2 stated Resident 1 was noncombative and cooperative. CNA 2 stated Resident 1 had a history of wandering but was easily redirected. CNA 2 stated staff were required to treat residents with respect, dignity, and patience. During an interview on 7/24/25 at 11:23 a.m. with the Housekeeper (HK), the HK stated on 7/17/25 he had just finished cleaning the room across from Resident 1's room and was in the hallway. The HK stated CNA 3 gave report (communication between staff members to ensure the continuity of care of a patient by tracking a patient's condition and progress during shift changes) to CNA 1 and CNA 1 was in a foul mood (a bad or irritable state of mind, often characterized by anger, frustration, or unhappiness). The HK stated after CNA 1 received report from CNA 3, CNA 1 proceeded to obtain the residents' vitals (blood pressure, heart rate, respiration rate, and temperature). The HK stated Resident 1 was coming out of Resident 1's room and was walking in the hallway when he witnessed CNA 1 grab Resident 1's left arm and stated to Resident 1, "You're starting already, this needs to stop." The HK stated CNA 1 was "rough and dragged Resident 1 back to her room and sat Resident 1 on her bed." The HK stated, "[CNA 1] grabbed a sweater and put it on Resident 1 aggressively (with force)" and stated to Resident 1, "You're always doing this, you need to stay in your room." The HK stated then CNA 1 left Resident 1 in the room and closed the door. The HK stated he was uncomfortable with what he had just witnessed and reported the incident to the Housekeeping Supervisor and the ADM. The HK stated CNA 1 was escorted out of the facility after the incident. The HK stated residents with dementia can be challenging but staff were required to treat all residents with dignity and respect. During an interview on 7/24/25 at 11:40 a.m. with CNA 3, CNA 3 stated on 7/17/25, CNA 3 gave report to CNA 1 during the afternoon shift change and shortly after, CNA 3 witnessed CNA 1 grab Resident 1's left arm in the hallway and stated to Resident 1, "You're starting already, this needs to stop." CNA 3 stated CNA 1 escorted Resident 1 back to her room forcibly and instructed Resident 1 to stay in her room and closed the door. CNA 3 stated she informed LVN 1 and the ADM of the incident. CNA 3 stated staff were required to treat residents with respect and dignity. CNA 3 stated staff need to advocate (support and represent the interests) for the residents and the behavior displayed by CNA 1 was grounds for disciplinary action including termination. During an interview on 7/24/25 at 12:01 p.m. with CNA 1, CNA 1 stated on 7/17/25, he started his shift after receiving report from CNA 3. CNA 1 stated he was obtaining vitals on the residents he was assigned to when he saw Resident 1 in the hallway walking towards the exit door. CNA 1 stated Resident 1 had a history of dementia and wandering. CNA 1 stated Resident 1 had a history of wandering into other residents' rooms and recently had a fall. CNA 1 stated he was trying to keep Resident 1 safe while obtaining vitals. CNA 1 stated he escorted Resident 1 back to her room to prevent her from leaving or wandering into other residents' room. CNA 1 stated Resident 1 did not go into other residents' room and Resident 1 did not exit the facility. CNA 1 stated he escorted Resident 1 to her room and instructed Resident 1 not to go into other resident's room. CNA 1 stated he was not aggressive with Resident 1. CNA 1 stated he was provided the mandatory abuse prevention and reporting in-service (education and training) upon hire but did not know what to do when he got frustrated with the residents. CNA 1 stated the facility investigated the incident and he was terminated on 7/21/25. CNA 1 stated he "should have backed off Resident 1" and not grab her the way he did. CNA 1 stated he should have informed other staff members to help supervise Resident 1 to ensure her safety. CNA 1 stated staff were required to treat residents with dignity and respect. During an interview on 7/24/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated on 7/17/25 she was informed by the ADM that CNA 1 escorted Resident 1 back to her room and instructed Resident 1 to stay in her room. The DON stated CNA 1 should not have spoken to Resident 1 the way he did and put Resident 1 back in her room because Resident 1 had rights to a dignified existence. The DON stated Resident 1 had dementia and required supervision and redirecting. The DON staff were required to treat residents with respect and dignity. The DON stated CNA 1's behavior during the incident was inappropriate and unacceptable. The DON stated CNA 1 was suspended on 7/17/25 pending the investigation and was terminated on 7/21/25. The DON stated mandatory abuse prevention and reporting in-services were provided annually and staff were required to request assistance when staff were unable to redirect a resident to ensure their safety. During an interview on 7/24/25 at 1:00 p.m. with the ADM, the ADM stated on 7/17/25 he was informed by staff of the incident with Resident 1 and CNA 1. The ADM stated CNA 1 was suspended immediately pending the investigation. The ADM stated staff witnessed CNA 1 mistreating Resident 1 during the incident. The ADM stated on 7/21/24, the ADM met with CNA 1 and CNA 1 stated he "was only redirecting Resident 1 for her safety" and that he did not understand what he did wrong. The ADM stated based on interviews with the witnesses, the decision was made to terminate CNA 1 on 7/21/25. The ADM stated CNA 1's treatment of Resident 1 on 7/17/25 was unacceptable regardless of Resident 1's behavior. The ADM stated staff were required to treat residents with dignity and respect and staff were required to ask for assistance when needed. During a review of the facility's P&P titled, "Resident Rights," dated 2/2021, the P&P indicated, "Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation..." During a review of the facility's P&P titled, "Abuse Prevention Program," dated 8/21/25, the P&P indicated, "Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Interpretation and Implementation: As part of the resident abuse prevention, the administration will: l. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual..." In violation of the above cited standard, the facility failed to: 1. Ensure Resident 1 was free from physical and verbal abuse when on 7/17/25, Certified Nursing Assistant (CNA) 1 was witnessed grabbing Residents 1's left arm forcefully and escorting Resident 1 back to her room. CNA 1 was witnessed saying to Resident 1, "You're starting already, this needs to stop," and "You're always doing this, you need to stay in your room." Resident 1 was then instructed by CNA 1 to remain in her room with the door closed. 2. Ensure the facility's policies and proc