Health inspection·February 11, 2021

F609 §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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report allegations of abuse made by Resident 1 to the Department within two hours, failed to thoroughly investigate, and failed to report the result of the investigation to the Department within five working days, in accordance with the facility’s policy and procedure. Resident 1 made four allegations: sexual abuse on 10/2/20, misappropriation of money on 10/6/20 and 10/9/20, and physical abuse on 11/20/20, these allegations were not thoroughly investigated and reported to the Department. These failures had the potential to compromise the safety of the resident as well as the resident’s belongings. A review of Resident 1's Admission Record (Face Sheet) indicated that Resident 1 was a 76-year-old female who admitted to the facility on 2/13/19. A review of Resident's record titled, "History and Physical Examination" dated 10/25/20 indicated that Resident 1 had diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), hypertension (high blood pressure), diabetes mellitus (high blood sugar levels) and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 1's Minimum Data Set (MDS, standardized resident assessment and care-screening tool) dated 2/10/20, indicated Resident 1 had intact cognitive skills (ability to think, decide and reason), was independent in bed mobility, transfer, locomotion, eating. The MDS indicated the resident required supervision/set-up from the staff with dressing, toilet use and personal hygiene. A review of Resident 1's record titled, "Interdisciplinary Progress Note" indicated the following: a. On 10/2/20, the meeting was conducted relating to Resident 1's allegation being touched on the back and shoulder by Licensed Vocational Nurse (LVN 1). b. On 10/6/20, the meeting was conducted relating to Resident 1's allegation of misappropriation of money against Social Service Director (SSD). c. On 10/9/20, the meeting was conducted relating to Resident 1's allegation of misappropriation of money against Certified Nursing Assistant 1 (CNA1). d. On 11/10/20, the meeting was conducted relating to Resident 1's allegation of physical abuse against Licensed Vocational Nurse 1 (LVN 1). During an interview on 11/17/20 at 9:34 am, Resident 1 stated the following: 1. On 11/6/20, she turned her call light on because Resident 2 (Resident 1's roommate) was choking. Resident 1 stated that LVN 1 came to the room and turned off the call light without asking what she needed and left. Resident 1 stated LVN 1 came back with a cardboard on his hand and stated, "I told you not to turn on the call light" and then LVN 1 slapped her. Resident 1 stated she told LVN 1, "Don't be slapping me." Resident 1 stated Resident 2 did not see but heard what was said. 2. In October 2020, LVN 1 was her medication nurse. Resident 1 stated when he was giving her medications, he started to touch her on her shoulder, close to the breast area. Resident 1 stated that he told LVN 1 to stop and then LVN 1 stated "How often do you take your panties off and get f ...k?" Resident 1 stated that she told him to get out of her room. Resident 1 stated that she did not tell anybody about the incident. 3. One month ago, almost $300 was taken out of her bank account. Resident 1 stated that she had asked the Social Services Designee (SSD) to help her access her account. Resident 1 stated that she did not know that SSD put his email on her bank account and went to a fancy restaurant. During an interview on 11/17/20 at 12:30 pm, the Administrator stated he did not report the allegations of abuse made by Resident 1 and result of the investigation to the Department and the Ombudsman because the facility was not able to substantiate the allegations. The Administrator also stated that the facility addressed Resident 1's allegations during the IDT meeting and that was the only documentation the facility had. The Administrator stated he did not interview other residents in the facility related to Resident 1's allegations. A review of the facility's policy and procedures titled, "Abuse Prevention," with a revision date of 3/15/18 indicated that the Administrator and Director of Nurses shall report incidents of suspected abuse to the Department and the Ombudsman, among others, within two hours of occurrence. The policy indicated that the Administrator shall report findings of investigation to the Department within five working days of the incident. The facility extensive efforts shall be carried out in the investigation and determination of unusual occurrences and/or events that may constitute abuse. The facility failed to ensure a written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved, including but not limited to: The facility failed to report allegations of abuse made by Resident 1 to the Department within two hours, failed to thoroughly investigate, and failed to report the result of the investigation to the Department within five working days, in according with the facility’s policy and procedure. Resident 1 made four allegations: sexual abuse on 10/2/20, misappropriation of money on 10/6/20 and 10/9/20, and physical abuse on 11/20/20, these allegations were not thoroughly investigated and reported to the Department. These failures had the potential to compromise the safety of the resident as well as the resident’s belongings. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.