Health inspection·April 28, 2025

F607 §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 resident s 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. §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 through established procedures. On 3/19/25 at 9:14 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding employee to resident abuse. The facility failed to implement their policy and procedure for abuse prevention and reporting when Resident 1 had a verbal altercation with Licensed Vocational Nurse (LVN) 1. The facility failed to: 1. Investigate the allegation of abuse between LVN 1 and Resident 1 on 2/11/2025. 2. Suspend LVN 1 on 2/11/2025, pending the results of the facility’s investigation, as indicated in the facility’s policy and procedure (P&P). 3. Prevent further contact between LVN 1 and Resident 1, following the incident of verbal altercation on 2/11/2025. 4. Notify the State Survey Agency (SA) and the Administrator (abuse coordinator) immediately or within two hours of an abuse allegation This deficient practice placed Resident 1 and other residents at risk for potential abuse from LVN 1, which could cause physical, mental, and emotional harm and had the potential for facility staff to under report all types of abuse allegations and placed Resident 1 at risk for further abuse. A review of Resident 1’s Admission Record indicated the resident was admitted on 11/6/2024 with diagnoses that included lack of coordination, muscle wasting (loss of muscle mass and strength), and depression. A review of Resident 1’s History and Physical (H&P), dated 11/6/2024, indicated the resident have the capacity to understand and make decisions. A review of Resident 1’s Psychiatric Progress Notes, dated 11/13/2024, indicated Resident 1 was assessed to not having delusions (false beliefs that are firmly held despite overwhelming evidence to the contrary) or hallucinations (sensory experiences that occur in the absence of an external stimulus). A review of Resident 1 ’s Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, indicated the resident had intact cognition (ability to process thoughts). The MDS also indicated the resident requires moderate assistance (helper does less than half the effort) for self-care activities such as bathing and personal hygiene. The MDS also indicated the resident requires moderate assistance for mobility such as rolling in bed, standing from a sitting position, and sitting from a lying position. A review of Resident 1’s Nursing progress notes, dated 2/11/2025, timed at 11:33 PM, entered by Registered Nurse (RN) 1, indicated the resident “called police at 7:20 PM complaining what happen this morning. Police asked the behavior of resident and left card in the RN book.” A review of Resident 1’s Nursing Progress Notes, from 2/11/2025 to 3/11/2025, did not indicate documented evidence that the facility staff interviewed Resident 1 regarding reason why the police was called to the facility. The Progress Notes did not indicate any documented evidence that an allegation of abuse was investigated involving Resident 1 and any staff, including LVN 1. A review of Resident 1’s social worker Progress Notes, from 12/11/2024 to 3/11/2025, did not indicate documented evidence that the social worker interviewed Resident 1 regarding why the police was called to the facility. A review of Resident 2’s Admission Record indicated Resident 2 was admitted on 7/17/2025, with diagnoses that included lack of coordination, hypertension (high blood pressure), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2’s H&P, dated 7/22/2024, indicated Resident 2 has fluctuating capacity to understand and make decisions. A review of Resident 2’s MDS, dated 3/5/2025, indicated Resident 2 has intact cognition. During an interview on 3/19/2025 at 2:59 PM with Resident 2 (Resident 1’s roommate), Resident 2 stated he heard a verbal argument between Resident 1 and a male staff (LVN 1). Resident 2 stated no one has interviewed him regarding that incident. During a phone interview on 3/19/2025 at 3:19 PM with the Police Office (PO), the PO stated he went to the facility in response to Resident 1’s call to the Police. The PO stated Resident 1 stated he had a verbal argument with a male staff, LVN 1. The PO stated he conducted a phone interview with LVN 1 regarding the allegation. During an interview on 3/19/2025 at 3:25 PM, LVN 1 stated on 2/11/2025 at around 2:30 PM, he heard Resident 1 yelling at CNA 1 on the hallway. LVN 1 stated he went to grab Resident 1’s wheelchair to take Resident 1 to the patio to calm him down. LVN 1 added that Resident 1 got up from his wheelchair, started yelling at him, and threw a baseball cap towards him. LVN 1 stated the PO called him on his phone the night of 2/11/2025 and interviewed him regarding the allegation that he threatened Resident 1 by allegedly telling Resident 1 that he will “bring 2 guys to hurt [Resident 1].” LVN 1 stated he did not report the allegation to the DON or the ADM. During another interview on 3/19/2025 at 3:37 PM, LVN 1 stated he was not suspended by the facility because of the altercation between him and Resident 1. LVN 1 added he spoke to Resident 1 again, two days after the altercation. During an interview on 3/19/2025 at 3:48 PM, RN 1 stated she remembered that a police officer visited the facility to interview Resident 1. RN 1 stated she attempted to interview Resident 1 one time, but Resident 1 did not want to talk about the incident. RN 1 stated she did not report to the DON or ADM that the police was called into the facility by Resident 1 or to ask for help in interviewing Resident 1 to find out the why the resident called the police. During an interview on 3/19/2025 at 4:40 PM, the DON stated she was never informed that the PO was called to the facility to investigate an allegation of abuse by Resident 1 against LVN 1. The DON stated LVN 1 never reported to her that he was interviewed by the PO. The DON stated that facility staff should have reported the incident to her or the ADM to investigate the alleged incident and protect the residents from further abuse. The DON stated if allegations of abuse are not addressed, residents could suffer harm such as physical harm and emotional distress. The DON added LVN 1 should have been suspended immediately to prevent further contact with Resident 1 and other residents. During a concurrent interview and record review on 3/19/2025 at 4:43 PM, Resident 1’s entire medical records were reviewed with the DON. The DON stated there is no evidence that the allegation of abuse was investigated. During a follow up interview on 3/20/2025 at 9:19 AM, the DON stated LVN 1 has been suspended due to the allegation of resident abuse. The DON stated LVN 1 should have been suspended right away on 3/11/25 after the alleged incident with Resident 1, until the investigation was conducted to prevent possible abuse to Resident 1 and other residents. The DON also stated LVN 1 should not have made contact again with Resident 1 after the allegation on 3/11/25. During an interview on 3/20/2025 at 9:44 AM, CNA 1 stated Resident 1 was yelling at her in the hallway because Resident 1 wanted a different CNA to care for him. CNA 1 stated LVN 1 approached Resident 1 and grabbed Resident 1’s wheelchair. CNA 1 added Resident 1 stood up and started yelling at LVN 1. CNA 1 stated LVN 1 told Resident 1 to “Respect the CNAs.” CNA 1 stated she was never interviewed regarding the incident between LVN 1 and Resident 1. CNA 1 stated she did not report what she saw or heard to the DON or ADM or the SA. During an interview on 3/20/2025 at 10:49 AM, the ADM stated verbal altercations are reportable because it could be ruled as a verbal abuse. The ADM stated if he is not in the facility, such as at night, a nurse could initiate the investigation of an incident involving a potential abuse allegation. During another interview on 3/20/2025 at 11:10 AM, the ADM stated CNA 1 and LVN 1 should have reported the incident to him, because all staff are mandated reporters of abuse. The ADM added RN 1 should have also reported that the Police was in the facility so that he could instruct the staff to investigate, and he could have further investigated the reason for the police officer’s visit to the facility. The ADM stated the verbal altercation with Resident 1 was a reportable incident for possible abuse. The ADM stated all allegations and incidents of abuse should be investigated because it is part of taking care of residents and to prevent abuse from reoccurring. A review of Resident 1’s “Behavioral Symptoms” care plan, initiated on 2/12/2025, indicated the resident has behavioral symptom or “yelling/screaming and cursing, threatening staff”. A review of the care plan did not include to take the resident to the patio, as an intervention for the behavior. The care plan included interventions for staff to: 1. “Honor resident’s rights at all times.” 2. “Identify times/approaches/staff that result in least resistance.” 3. “When behavior occurs, remind resident of potential risks. Coax but do not force compliance.” A review of the facility’s job description for a Registered Nurse (RN), undated, indicated it is a job function of an RN to comply “with abuse prevention and reporting policies and procedures.” A review of the facility’s job description for a Licensed Vocational Nurse (LVN), undated, indicated it is a job function of an LVN to comply “with abuse prevention and reporting policies and procedures.” A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating”, revised 9/2022, indicated: 1. “All reports of resident abuse… are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.” 2. “Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.” 3. “Investigations may be assigned to an individual trained in reviewing, investigation, and reporting such allegations.” 4. “The individual conducting the investigation as a minimum: a. “Interviews the person(s) reporting the incident.” b. “Interviews any witnesses to the incident.” A review of the facility’s job description for a Registered Nurse (RN), undated, indicated it is a job function of an RN to comply “with abuse prevention and reporting policies and procedures.” A review of the facility’s job description for a Licensed Vocational Nurse (LVN), undated, indicated it is a job function of an LVN to comply “with abuse prevention and reporting policies and procedures.” A review of the facility’s job description for a Certified Nursing Assistant (CNA), undated, indicated it is a job function of a CNA to “report all accidents and incidents [they] observe on the shift that they occur.” The job description also indicated that a CNA is to “report all allegations of resident abuse.” A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating”, revised 9/2022, indicated: 1.  If resident abuse “is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.” 2.  “’Immediately’ is defined as within two hours of an allegation involving abuse…” 3.  “All reports of resident abuse… are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.” A review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention Program”, revised 12/2016, indicated “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.” The P&P indicated that the admin will “identify and assess all possible incidents of abuse.” The P&P further indicated to investigate and report “any allegations of abuse within timeframes as required by federal requirements. The facility failed to implement their policy and procedure for abuse prevention and reporting when Resident 1 had a verbal altercation with Licensed Vocational Nurse (LVN) 1. The facility failed to: 1. Investigate the allegation of abuse between LVN 1 and Resident 1 on 2/11/2025. 2. Suspend LVN 1 on 2/11/2025, pending the results of the facility’s investigation, as indicated in the facility’s policy and procedure (P&P). 3. Prevent further contact between LVN 1 and Resident 1, following the incident of verbal altercation on 2/11/2025. 4. Notify the State Survey Agency (SA) and the Administrator (abuse coordinator) immediately or within two hours of an abuse allegation This deficient practice placed Resident 1 and other residents at risk for potential abuse from LVN 1, which could cause physical, mental, and emotional harm and had the potential for facility staff to under report all types of abuse allegations and placed Resident 1 at risk for further abuse. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1 and all o