Health inspection·May 10, 2021

F607 §483.12(b)(1)-(4) Develop/Implement Abuse/Neglect Policies §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. Based on observation, interview, and record review, the facility failed to implement their abuse policy for three of three sampled residents (Residents 16,18, and 56) when, 1. Residents 16, 18, and 56 were not protected from physical and verbal abuse by certified nursing assistant M (CNA M) and, 2. Residents' 18 and 56 allegations of abuse were not reported. These failures put the residents at risk for further abuse. 1. Resident 16 had diagnoses including dementia (memory loss) and altered mental status. Resident 16 was non-verbal and had severe cognitive impairment. During the initial tour on 4/19/21 at 12:53 p.m., Resident 94 (co-resident) stated Resident 16's hands were slapped by CNA M. During an observation on 4/19/21 at 12:53 p.m., Resident 16's right hand was discolored (dark brown) while no discoloration on his left hand was noted. Review of Resident 16's interdisciplinary team (IDT) notes dated 4/14/21 indicated that Resident 94 (co-resident) had reported that CNA M had slapped Resident 16's hand on several occasions when Resident 16 was not cooperating with care. 2. During an interview with Resident 56 on 4/23/21 at 9:44 a.m., Resident 56 stated CNA M had cursed him twice which made him "feel so bad." Resident 56 also stated he did not feel safe with CNA M and was afraid that CNA M would be more aggressive. During a concurrent observation and interview with Resident 18 on 4/23/21 at 9:54 a.m., Resident 18 stated CNA M had pulled both of her arms and had yelled at her to "shut up". Resident 18's left arm and up to half of the forearm was dark purple in color. During an interview with Resident 59 (co-resident) on 4/23/21 at 9:54 a.m., Resident 59 stated she witnessed CNA M yell and hurt Resident 18 by pulling on her arms. During an interview on 4/23/21 at 10:56 a.m. with the administrator (ADM), he affirmed that he had spoken with Resident 56 regarding his allegations. During an interview on 4/23/21 at 11:39 a.m. with the ADM, he stated he reported the allegation concerning Resident 16 to the state agency but did not report the allegations concerning Residents 18 and 56. During an interview with the Director of Staff Development (DSD) on 4/23/21 at 11:57 a.m., she stated Resident 56 told her that CNA M was frequently frustrated when Resident 56 asked for help. The DSD stated CNA M called Resident 56 dirty and disgusting. The DSD also stated Resident 18 had told her that CNA M was always in a hurry and would get upset when Resident 18 needed to be repositioned. Resident 18 also told DSD that CNA M was always rough when helping Resident 18 with toileting and would grab Resident 18's wrists tightly. A review of the "Grievance/Complaint Resolution Report" that was filled out for Resident 18 dated 4/14/21 indicated CNA M became upset when help was requested. CNA M was "rough" when assisting with activities of daily living (ADL) and would cause discomfort to Resident 18's arms. The form also indicated Resident 18 did not feel comfortable telling CNA M of discomfort during care in the past. Review of the "Grievance/Complaint Resolution Report" that was filled out for Resident 56 dated 4/14/21 indicated CNA M was frequently frustrated while providing care and would call Resident 56 names. Review of the "Verification of Incident Investigation/Administrative Summary" for Resident 16 dated 4/22/21 indicated Resident 94 (co-resident) had witnessed CNA M slap the hands of Resident 16 multiple times over the past few weeks. Residents 18 and 56 had expressed that CNA M had been rude. A review of the facility's "Abuse Prevention, Intervention, Investigation, & Crime Reporting" policy revised 11/2016, indicated the resident has the right to be free from abuse. "The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse... In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment... are reported immediately; but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law." This violation had a direct or immediate relationship to the health, safety, or security of residents.