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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1116 EAST HIGHWAY 20

CORRECTIONVILLE SPECIALTY CARE
CORRECTIONVILLE, IA 51016
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
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DEFICIENCY)
F 000 INITIAL COMMENTS F 000
Correction date: __________________
The Correctionville Specialty Care Nursing Home

is not in compliance with 42 CFR Part 483
Requirements for Long Term Care Facilities due
to the following deficiencies written during the
investigation of complaints #116629-A and
#116630-A, conducted November 6, 2023 to
November 20, 2023.
Findings for complaints #116629-A and 116630-A

will be sent to the facility at a later date under
separate cover.
F 600 Free from Abuse and Neglect F 600
SS=J CFR(s): 483.12(a)(1)
§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.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or

physical abuse, corporal punishment, or
involuntary seclusion;
This REQUIREMENT is not met as evidenced
by:
Based on clinical record review, law enforcement
incident review, facility policy review, resident and
staff interviews, the facility failed to keep
residents safe from sexual abuse and financial
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LSNP11 Facility ID: IA0406 If continuation sheet Page 1 of 73
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F 600 Continued From page 1 F 600

exploitation for 1 of 3 residents (Resident #1).
Resident #1 reported a male Certified Nurse Aide
(CNA) forced her to perform sexual acts on him.
In addition, that male CNA and another CNA
transferred money from her account using an
electronic money transferring service. Despite the
allegation of sexual abuse from the male CNA to
Resident #1, the facility failed to prevent him from
working with other vulnerable residents in the
corporation.
Findings include:
The State Agency informed the facility of the

Immediate Jeopardy (IJ) that began as of
10/23/23 on 11/9/23 at 4:00 PM. The facility
removed the IJ and decreased the scope to a "D"
on 11/13/23 with the following actions:
a. The facility provided the following education:
i. Dependent adult abuse and sexual abuse
including consensual vs. non-consensual
education and the need to immediately report the
allegation on 11/10/23.
ii. Spotting Signs of Elder Abuse to include
caretaker boundaries on 11/10/23.
iii. The facility's expectations regarding
purchasing personal items for residents on
11/10/23.
iv. Discharge/transfer policy, highlighted
resident-initiated discharge including meeting the
needs of Resident #1 welfare on 11/10/23.
v. Supervision of outdoor visits on 11/13/23.
b. The facility interviewed residents on all the alert
and oriented residents on 11/11/23. In addition,
the facility audited the remaining residents for any
non-verbal signs of abuse.
c. The facility updated the Agency Orientation
Checklist to include Abuse Protocol to highlight
dependent adult abuse reporting policy and
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professional boundaries.
Resident #1's Minimum Data Set (MDS)

assessment dated 9/24/23 identified a Brief
Interview for Mental Status (BIMS) score of 14,
indicating intact cognition. The assessment
reflected that Resident #1 did not have behaviors.
Resident #1 required limited assistance from one
person for transfers, dressing, toilet use, and
personal hygiene. The MDS listed Resident #1 as
frequently incontinent of urine and always
continent of bowel. The MDS included diagnoses
of disorder of the kidney, heart failure,
hypertension (high blood pressure), diabetes
mellitus, anxiety, depression, Post-Traumatic
Stress Disorder (PTSD), and malignant neoplasm
of upper lobe (lung cancer). The assessment
indicated that Resident #1 almost always had
pain.
The Care Plan included the following Focuses

dated 10/3/23:
a. Resident #1 planned to rehab to home. The
Goal listed that Resident #1 would transition back
to the community.
b. Activities of daily living (ADLs). The
Interventions directed that Resident #1 could
independently provide her own hygiene, toilet
use, and transfers.
c. Resident #1 is independent in the facility. The
Interventions reflected that Resident #1 used a
front wheel walker.
The Discharge Summary note dated 10/25/23 at

12:00 PM, reflected that the facility discharged
Resident #1 to a homeless shelter on 10/25/23.
The Sheriff's Office Incident Report dated 11/1/23

at 6:22 PM, reflected that a Sheriff's Office
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Representative interviewed Resident #1 about
allegations of sexual abuse. She said that during
her time as a resident in the nursing home, Staff
I, CNA, sexually abused her. She stated that
while taking care of her, Staff I would touch and
kiss her inappropriately on the back of the neck
and on her feet. She said that 2-3 weeks prior to
her discharge, she went outside the facility to
have a cigarette and it had been raining. Staff I
asked if she would like to have her cigarette in his
car and she agreed. He wheeled her to the car
and while in the vehicle, he forced her to perform
oral sex on him. She described the vehicle as a
small red car parked by the row of trees near the
highway.
On 11/14/23 at 2:15 PM, the Police Officer who

interviewed Resident #1 on 11/1/23 described her
as forthcoming but very embarrassed when she
came in to the report abuse. He said that when
she tried to describe what happened, she
stumbled and had difficulty describing the sexual
act. She mentioned being heavily medicated
while at the facility and could not give consent.
She told the officer that Staff I sent her a sexually
explicit video of himself.
On 11/6/23 at 2:13 PM, Resident #1 said that

when she reported her abuse to a couple of staff
members, somehow, they twisted the story
around. Due to this she did not trust anyone at
the facility any more. She said that the
Administrator came into her room one day,
yelling, and told her that she had to leave
because the staff reported that she provided
sexual favors for cigarettes. Resident #1 said that
staff took her outside to have cigarettes, and she
shared with a couple of them. Staff I sexually
attacked her. She could not remember the date
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when Staff I took her to his car and made her
perform oral sex on him. She said that he treated
her nice and spent time with her. She thought that
she may have gave him the wrong impression
when she sent him texts. He then sent her a
video of him pleasuring himself.
When asked to share the sexually explicit video

for the investigation, on 11/9/23 Resident #1 sent
the video of a male masturbating. The phone
revealed that Staff I sent it from his phone. In
addition to the text transactions, Resident #1's
phone included the transfer of money from her
account to Staff I's Cash App on 10/16/23.

she took a lot of pain medications at the facility,
that made her mind fuzzy, and she could not be
clear on the actual date of the incident. She
remembered that Staff I sent the sexually explicit
video after the incident, but before the Cash App
transfer because he told her about the video
when he had her in the car (A screenshot of text
messages between Staff I and Resident #1
confirmed that Staff I sent the explicit video on
10/12/23). Resident #1 said that initially, she felt
very safe with Staff I. He spent time with her, took
an interest in her, and they joked around a lot.
Even though she could mostly do things
independently, he would come into her room and
help her with things. She said that he changed
her bedding after being incontinent. This
confused her, she did not understand why he
would do that kind of thing, and then show an
interest in her. One time he helped her with a
nightgown that had a string on the back at the
neckline. He tied the string and then kissed her
on the neck without saying anything. This
surprised and confused her about the interaction.
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Another time, as she put on her socks, Staff I was
in the room. He offered to put one on, held her
foot, stoked it and said "you have beautiful feet,"
then kissed her foot. She felt surprised by this but
no one said anything and he acted like it was no
big deal. She said used a wheelchair on the night
that Staff I took her to his car. He wheeled her
down to the area with trees, in the dark and
pouring down rain. He laughed and joked with her
until they got into the car. Once inside, his mood
changed, he pulled a bottle of Crown Royal
(alcohol) out from under his car seat and told her
that he started drinking it at the beginning of the
day. She said that he then put on some loud,
"dirty" music. She said that he shared with her
that he made and recorded his own music. She
reported the lyrics as violent. Due to the
darkness, she did not see his penis outside his
pants. With his right hand he grabbed the back of
her neck, pulled her hair, and shoved her head
into his lap. She said that while she had his penis
in her mouth, she could see a bright light coming
from his phone in his left hand. She knew that
meant that he videotaped her. Resident #1 said
that after the incident, she went directly to her
room and did not talk to anyone. She
remembered that Staff I did not work for several
days after the incident. Then they never talked
about the event.
Resident #1's Clinical Physician's Orders

reviewed on 11/14/23 at 10:14 AM included the
following medications that could cause
drowsiness:
a. Dilaudid (opioid pain medication) 2 milligrams
(mg) every 4 hours as needed for pain
b. Lorazepam (antianxiety medication) 0.5 mg
every 12 hours as needed
c. Trazodone (antidepressant used for sleep) 100
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mg at bedtime
d. Morphine (opioid pain medication) sulfate 30
mg twice a day.
A review of the weather history indicated that it

rained with showers on 10/12/23 in the area.
Timesheet records show that Staff I worked on

10/12/23 from 6:02 PM - 10:43 PM.
Resident #1's text messages revealed that she

sent Staff I a message at 9:57 PM on 10/12/23,
then again at 10:58 PM in which she reminded
him to send the video. He then sent the video,
and on 10/13/23 at 7:42 PM he sent a message
to her asking "how are you?". She did not
respond to that message until 10/15/23 at 8:16
PM and said that she was not feeling well. On the
16th at 5:24 PM she offered to Cash App some
money to him if he would buy her some
cigarettes. At 10:38 PM a transfer of $10.00 went
from Resident #1's account to Staff I's account,
with another $21.00 sent on 10/18/23 at 2:03 PM.
Resident #1's Cash App included a transaction on
10/22/23, of $22.00 sent to Staff F's, CNA,
account.
On 11/16/23 at 8:56 AM Staff F admitted that she

accepted money from Resident #1's Cash App to
buy her some pop and chips. She said she knew
it was not right.
On 11/8/23 at 10:48 AM, Staff A, Dietary Aide

(DA), said that on the evening of 10/23/23 while
she waited outside the facility for a ride after her
shift, she sat on the patio with Resident #1. At
that time, Resident #1 told her that Staff I bought
her cigarettes. He would take her phone and
transfer money into his own Cash App. She told
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her that he took her to his car one night and
forced her to perform oral sex. She said that they
were drinking alcohol and she did not want
anyone to know about it. Staff F, Nurse Aide (NA),
then stopped over and entered the conversation
when Resident #1 told them that she had a video,
but her phone needed to charge, so she could not
show them. She described Resident #1 as
trembling when she told them the story. Staff A
said Resident #1 reported being afraid of what he
might do if he knew she told anyone.
On 11/8/23 at 10:32 AM, Staff F said that on the

evening of 10/23/23, while Resident #1 sat
outside with Staff A, she approached them. Staff
A looked at Resident #1 and asked "can I tell
her?" Resident #1 shook her head "yes" and Staff
A proceeded to tell her that Staff I sent her a
video of himself masturbating. They agreed that
they needed to report that to the Administrator.
The next morning around 10:00 AM they both
went in the next morning.
On 11/8/23 at 2:18 PM, the Administrator said

that on 10/24/23, a couple of staff members told
her that there was a situation with Staff I buying
cigarettes for Resident #1, and that he used a
Cash App on his phone. The Administrator said
that she had Staff I come into her office that
morning. He showed her the Cash App receipt on
his phone for $10.00, and she suspended him
from the building. When asked about the
allegations of sex, the Administrator said that she
confronted Resident #1 about providing sexual
favors for cigarettes, but she denied it. She said
that Staff I denied any sexual activity with
Resident #1. He acknowledged that he would
take her out to smoke but denied anything sexual.
The Administrator said that Resident #1 wrote a
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letter stating that it was false and denied
everything.
A hand-written note dated 10/24/23 at 8:52 AM,

signed by Resident #1, indicated that the
Administrator had confronted Resident #1 and
accused her of providing sexual favors for
cigarettes. Resident #1 reported being very upset
by the allegations, and that she would never do
anything so vile. She denied the allegations and
the hand-written note lacked any reference to
forced sexual acts.
On 10/24/23, the Regional MDS Coordinator (RC)

added the following to Resident #1's Care Plan;
a. Staff caught Resident #1 outside in front of the
building smoking.
b. Resident #1 had a behavior problem that
involved manipulating staff, and making up
stories that did not happened.
According to a Social Services Behavior History

Evaluation dated 9/26/23 at 9:28 AM, Resident #1
did not make accusatory statements, described
her as not worried, not anxious, not tearful, and
did not have mood swings.
The follow-up Behavioral History completed on

10/10/23 at 1:58 PM resulted with the same
conclusion.
On 11/13/23 at 8:47 AM the RC described her

role as to oversee the MDS coordination for the
facilities in the region. She said that she would be
in the building about once a week but she would
mainly spend her time with the MDS staff and
leadership, resulting in her not being very familiar
with the residents. She said that they talked about
the residents in morning meetings. She
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acknowledged that she made the addition to
Resident #1's Care Plan on 10/24/23. She
explained it as a group effort to include that area
of focus, based on Resident #1 sharing and using
snacks to her advantage with staff. She said that
Resident #1 told a story about how the hospital
tied her down and she received the wound on her
wrist from that, but she did not know about
examples of any made-up stories while at the
facility. When asked about allegations against
Staff I, she said she did not know anything about
that staff member, or allegations of abuse. She
maintained that in their leadership meeting when
she changed the care plan on 10/24/23, they did
not talk about the abuse allegations
On 11/13/23 at 9:00, Staff D, Registered Nurse

(RN), said that when RC came to the morning
leadership meeting that she attended on
10/24/23, they discussed Resident #1's abuse
allegations about Staff I.
On 11/6/23 at 1:33 PM, Staff J, NA, said that

Resident #1 would spent most of her days in her
room sleeping, then she came out in the evenings
and nights. In the days leading up to her
discharge, she started coming out more in the
evenings and interacted with others. She would
ask to go outside even after dark and/or cold out
and sit on the bench on the porch. She could not
go too far with her walker before getting fatigued.
On 11/6/23 at 1:38 PM Staff K, CNA, said that

Resident #1 only went out at night and would sit
out there for long periods of time. She sat with
Staff I for more than an hour. One-night Staff I
came back inside after 11:00 PM and his shift
ended at 10:00 PM.
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On 11/6/23 at 3:49 PM, Staff L, CNA, said that
she witnessed Staff I spending time with Resident
#1 outside on the patio. They would be out there
for over an hour.
On 11/8/23 at 11:55 AM, Staff M, CNA, said she

only worked at the facility a couple of times and
she would never go back. She said that the last
day she worked at the facility, the Administrator
yelled at Resident #1, giving her only 30 minutes
to pack up her room and leave. She described
Resident #1 as crying and shaking. She said that
Resident #1 told her that Staff I raped her and he
took a video of it. While Staff M helped Resident
#1 pack her things on 10/25/23, the Administrator
and her yelled at each other. Resident #1
appeared very upset.
On 11/8/23 at 8:17 AM, Staff E, Registered Nurse

(RN), said that she worked the overnight shifts.
She described Resident #1 as good with the staff
and the other residents. Resident #1 had food
items delivered to the facility, she was kind, and
would share her snacks. She would often see her
out on the patio. Staff I would work until 10:00 PM
and then spend time with Resident #1 outside.
On 11/8/23 at 3:30 PM, Staff Q, CNA, said that

she did not see any interactions between
Resident #1 and Staff I. She did report that she
saw the video of him masturbating. Staff Q said
that she worked with him before. She described
him as very invasive and would get into "your
bubble." She said that Resident #1 told her about
Staff I forcing her head in his lap to perform oral
sex and that he recorded it.
On 11/9/23 at 8:50 AM, Staff I said that on

10/24/23, his schedule had him working a 6a-6p
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shift. At around 9:00 AM, the Administrator called
him into her office. She asked him if he
purchased cigarettes for a resident, he told her
that he did and showed her the Cash App. He
said "the lady sent me money and I bought her
cigarettes." The Administrator asked him if he
ever took Resident #1 in his car to go purchase
cigarettes and he told her that he did not. He said
he chose to leave the facility on 10/24/23
because he would not feel comfortable working
there anymore. He said that he went to a sister
facility and finished up a shift that same day. He
denied having any kind of relationship with
Resident #1 and said that he would sit with her a
little bit on the patio. He denied sending her any
messages and said that he did not feel he did
anything wrong with accepting her money for the
purchase of cigarettes. Staff I went on to say that
he worked in different states and did not have a
problem with buying things for residents. Staff I
said that he did not spend much time with
Resident #1. When asked if he thought that she
had the wrong impression about their
relationship, Staff I asked what the questions
were about and did not understand the reason for
the interview. He maintained that the
Administrator did not bring up or ask about any
sexual interactions between him and Resident #1.
Staff I then chuckled and said that he worked as
an intelligence officer and learned to record
things. He thought that he may have a recording
of the interaction between himself and the
Administrator. He said "I am keeping my
magnetism, I can overcome obstacles ... I am a
stellar worker." He said that the company begged
him to work other shifts since 10/24/23. He
mentioned three other facilities that he completed
shifts after the 24th. He did not understand that if
they thought he did something wrong, why they
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allowed him to continue to work for the company?
He reported feeling upset and described the
allegations as preposterous.
On 11/9/23 at 5:40 PM, Staff C, CNA, said that

Resident #1 went out at night and she knew when
what time she could her pain pills. Resident #1
would go out and sit on the patio for hours, Staff
C did not know what she did out there for so long,
"I got work to do." She said that Staff I would
hang around outside long after his shift ended at
10:00 PM. Sometimes he slept in his red car
overnight in the parking lot at the facility. She
described Staff I as "flirty" with some staff
members.
On 11/14/23 at 9:00 AM the Regional Director of

Nursing said that their leadership team had a
"rapid response" phone call regarding the
concern with Resident #1 on 10/24/23. She said
that most of the conversation was related to the
concern about money exchange from resident to
staff. The conversation included very little
discussion regarding sexual innuendos. She said
that the Administrator conveyed to them that Staff
I only made a motion that simulated
masturbation. The meeting did not include
anything about allegations of forced sexual
activity.
On 11/14/23 at 2:50 PM the Regional Manager

said the rapid response team did not get all the
information, or accurate information from the
Administrator to determine the next steps. She
said that had they known all the details, they
would have made different decisions.
A review of the personal file for Staff I included a

Corrective Action Form dated 10/25/23. The form
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described the infraction on 10/23/23 as a resident
reported that she transferred money to him on a
mobile app to purchase cigarettes for her. He
received a verbal warning not to take money for
any reason from a resident. The verbal warning
did not include any references to a sexual abuse
allegation.
According to an annual facility survey report

dated 10/19/22, Staff I recorded a resident
without her consent or knowledge. His personal
file lacked a corrective action form or any
indication that the facility addressed that incident
with him.
Staff I's timesheet showed that he continued to

work with vulnerable elderly population in their
facilities on 10/24/23 from 2:04 PM - 7:02 PM,
10/28/23 from 10:19 PM - 6:14 AM, and on
10/30/23 at 10:01 PM - 6:00 AM.
According to the Dependent Adult Abuse policy

dated November 2019 directed that all residents
had the right to be free from abuse, neglect,
misappropriation of resident property, and
exploitation. This included prohibiting nursing
staff from taking pictures that result in person
degradation, including the taking or use of
photographs or recording in any manner.
F 607 Develop/Implement Abuse/Neglect Policies F 607
SS=G CFR(s): 483.12(b)(1)-(5)(ii)(iii)
§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,
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§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.
§483.12(b)(5)(ii) Posting a conspicuous notice of

employee rights, as defined at section 1150B(d)
(3) of the Act.
§483.12(b)(5)(iii) Prohibiting and preventing

retaliation, as defined at section 1150B(d)(1) and
(2) of the Act.
by:
Based on interviews, record review and policy
review the facility failed to prevent retribution to a
resident and a staff member for 1 of 3 residents
(Resident #1). Resident #1 reported that a male
Certified Nurse Aide (CNA) sexually abused her.
After the facility learned of the allegations on
10/24/23, they discharged Resident #1 to a
homeless shelter on 10/25/23 with only
approximately 30 minutes to pack. In addition,
Staff P reported that the facility suspended her
after she confronted the Administrator regarding
the need to report the abuse. The facility
suspended Staff Q from work for not reporting
abuse within 2 hours after she learned about the
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allegation. At the time she reported the allegation,
the facility already knew from other staff. The
facility asked her to share information related to
the abuse to speed up their investigation so she
could return to work sooner. Due to the facility's
treatment of Resident #1 after the facility learned
of the allegation of abuse, caused Resident #1 to
become afraid and cry during an exchange of
yelling between her and the Administrator.
Findings include:

pain.

dated 10/3/23:
to the community.
use, and transfers.
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front wheel walker.

perform oral sex on him. Resident #1 said when
planning her discharge, the Social Worker (SW)
told her that she planned to help her find housing
so her son could come and live with her. The
Women's and Children's Shelter was an option
but her son was too old to go there. She said she
felt like the facility kicked her out because of the
lies told about her.

her about a situation with Staff I buying cigarettes
for Resident #1, and that he used a Cash App on
his phone. The Administrator said that she had
Staff I come into her office that morning. He
showed her the Cash App receipt on his phone
for $10.00, and she suspended him from the
building. When asked about the allegations of
sex, the Administrator said that she confronted
Resident #1 about providing sexual favors for
cigarettes, but she denied it. She said that Staff I
denied any sexual activity with Resident #1. He
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acknowledged that he would take her out to
smoke but denied anything sexual. The
Administrator said that Resident #1 wrote a letter
stating that it was false and denied everything.

Administrator confronted Resident #1 and
forced sexual acts.

The Encounter Note dated 10/24/23 at 12:00 AM

signed by the Advanced Registered Nurse
Practitioner (NP) on 10/26/23 at 8:08 PM
reflected that Resident #1 saw the NP on
10/24/23. At that time, Resident #1 cried and
stated that she had a lot of pain. They discussed
getting her an appointment with the pain clinic.
Resident #1 told her about her leaving the facility
in 1-2 days, as the staff falsely accused her of
being inappropriate with a staff member. She
planned to leave and be at the homeless shelter
for 6 months. The provider received a call from
the facility on 10/25/23 indicating that day they
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planned to discharge Resident #1. The NP
recommended to follow-up for medication refills in
six months and she would provide a 7-day supply
of medications.

added the following to Resident #1's Care Plan:
building smoking.


conclusion

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not talk about the abuse allegations.

On 11/9/23 at 12:15 PM, Staff H, Housekeeping

Staff, said that on the morning of 10/25/23, she
loaded up the remainder of Resident #1's
belongings in her personal vehicle and drove
them to the shelter. The transportation provider
came with a very small car and they could not get
all her items in that vehicle. As she helped
Resident #1 pack her things, she appeared very
angry, crying, and said that she felt the facility
kicked her out. She kept asking to speak to
someone above the Administrator about what
was happening. She got to the shelter with
Resident #1 items at about 1:30 PM that day.
On 11/8/23 at 11:12 AM the Social Worker (SW)

reported the transfer of Resident #1 to the
homeless shelter as appropriate as she came
from there per her lifestyle choice. Resident #1
always had a goal to discharge and reunite with
her son. When asked if she told the staff at the
shelter the level of need before sending Resident
#1 to the shelter, she replied "yes and no." The
SW continued by expressing Resident #1's
"behaviors" related to impulsivity and lack of
follow through. When inquired about Resident
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#1's level of medical needs, she responded that
therapy told her that Resident #1 could use a
walker. The Regional Director of Nursing
arranged to get her a walker to take with her but
she wanted to get out. She said that after
Resident #1's admission to the shelter, she called
911 that night, but she did not know what
happened after that. She denied knowing
anything about Staff I or cigarettes. She
maintained that she had Resident #1's
permission to make the arrangements to go to
the shelter.
On 11/9/23 at 10:45 AM during a telephone call,

the SW said that the Administrator reached out to
the homeless shelter to ask about admitting her.
Afterwards, she made the transportation
arrangements. She said that she got a call from a
very upset shelter representative the next day
about Resident #1 and said that she "faked a
heart attack." They sent her to the hospital, and
they could see what she was like. The SW told
her that they could not take her back because of
her behaviors and manipulation. She met all her
goals and she wanted to go to there. When
questioned about if she sent Resident #1's
medical information with her, she replied no, as a
homeless person off the street did not come into
a shelter with their medical diagnosis information.
As that is what they do.
On 11/13/23 at 3:00 PM the SW said that they put

a discharge checklist on the wall in her office so
they can go down the list and make sure they are
hitting on the planning points. She said the
24-hour notice challenged her with the need to
get the transportation. The SW had a
conversation with Resident #1 about discharge
on Friday or Monday. She questioned about he
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being okay to discharge sooner as they had a
4-hour notice. Resident #1 reported she was fine
with it, as it was better because then her sister
did not have to come and get her.
A review of a voice recording from the

transportation company, dated 10/25/23 at 7:28
AM, revealed that the SW called for a ride at that
time without Resident #1 in the room with her.
When the SW made the arrangements, she
chose the 4-hour pick-up time and said "that
works for me." They finalized the arrangements
and once the company found a driver, they would
notify them of the time of arrival.
On 11/15/23 at 8:00 AM Staff N, Registered

Nurse (RN), said early that morning, Resident #1
went around to say good bye to other residents
and staff. Later that morning when she found out
that she only had a half hour to get everything
together and packed she started to cry. Resident
#1 expressed that she felt like the facility kicked
her out. Staff N said that she understood that they
had a plan for discharge but it came very
abruptly. Staff N reported that she had concerns
that Resident #1 went to a homeless shelter
without nursing services especially when she
needed monitoring as the provider just changed
her hypertension.
On 11/9/23 at 8:15 AM Shelter Staff 1 (SS1)

called back and said that the transportation
company just dropped Resident #1 off at the
shelter with no paperwork and no phone call. She
said they did not typically accept residents from a
hospital or nursing home that way. They need to
know what level of care the resident required so
they can determine if they are appropriate or if
they can handle them. On 10/25/23 around 1:00
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PM the transportation company dropped her off.
Initially, the cab driver dropped her off at a safe
house intended for domestic violence victims.
The driver did not know what to do with her when
they would not accept her there, so, they called
the facility, who told them to take her to the
homeless shelter. SS1 did the intake herself and
then she had to leave early that day. Her
daughter worked there in the afternoon and she
called 911 due to Resident #1 shaking, falling,
and unstable around 4:00 PM in the afternoon. At
6:15 AM on 10/26/23 the hospital returned her
soiled back at the shelter. They got her a room to
clean up and she talked to a friend on the phone.
Around 11:00 AM on the 10/26/23, Resident #1's
friend came and picked her up. She said she did
not know what happened from there. They try not
to get too involved in the resident's lives or
situations once they leave the shelter. She said
the facility made her very upset for just dropping
off Resident #1 without first having a consultation
on her level of need. She explained that "we have
children here" and do not have nursing staff. She
did call and talk to the SW who said that she did
not make the arrangements and indicated that
they would not take Resident #1 back because
she made allegations against staff.
On 11/13/23 at 7:26 AM SS1 that she knew for a

fact that no one talked to Shelter Staff 2 (SS2),
before Resident #1 showed up at their door. She
said that when they get residents from a facility or
hospital, they put them on a list. When Resident
#1 showed up she checked the list, which did not
include her. SS2 called back to the facility the
next day and talked to the SW but not before.
SS1 was very sure of that because she is the
manager, they all stay on top of who is calling and
who is on the list. When Resident #1 showed up
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at their door, she told them that she did not know
where they sent her. She said that they will never
do business with that facility ever again or with
"that SW lady."
On 11/13/23 at 2:32 PM SS2 said that the first

day she talked to anyone at the facility was the
day that Resident #1 showed up at their door.
They write down their notes or document on the
computer and they have no notes that someone
contacted them regarding Resident #1 coming
there. Resident #1 was at the door, concerned
about the driver because he was on the phone
with the facility. Originally, he went to the wrong
place first and then did not know what to do with
her things. Then the SW called back just after
Resident #1 got there and SS2 told her that
Resident #1 could barely walk, shook, and had
shortness of breath. Resident #1 worried about
holding up the driver. SS2 recalled her surprise
when they started unloading all of Resident #1's
things and said that they could only allow 2 bags.
SS2 said that Resident #1 he had a TV and
everything. SS2 talked to the SW on the phone
telling her about Resident #1 not stable and she
did not know if they could take care of her there.
The SW told her that because of her behaviors
they could not take her back. She told the SW
that they did not know about her coming, the SW
responded that she was sure someone took care
of that. SS2 started the intake and later called
non-emergent care to pick her up because she
seemed so unstable. She did come with some
medications, they are responsible for taking them
on their own. SS2 said if Resident #1 stayed
there before, it was a long time ago because she
did not have a record of her being there.
On 11/13/23 at 10:30 AM Staff P, Former Office

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Manager, said that she no longer worked at the
facility. She felt that the administration was
looking for some reason to terminate her because
she questioned them on reporting the events to
the proper authorities. Staff P said that she heard
about the allegations of abuse later in the day on
10/24/23 and sent a text to the Regional Manager
at 5:30 PM, expressing that they should report the
event. She then she got a call back from
corporate that Resident #1 recanted the
allegations so they did not think they needed to
report it. She said that when she came into work
on the 25th, her office had been in shambles
because they were looking through for missing
orders. They suspended her because of the
missing orders.
On 11/15/23 at 2:20 PM Staff Q, CNA, explained

that the facility suspended her from working
pending investigation, because she did not report
allegations of abuse within 2 hours. When she
learned about the incident, the facility already
knew about the incident from someone else. She
said that the facility told her that their investigation
could speed up if she could provide a copy of any
video or text messages that exchanged between
Resident #1 and Staff I.

Nursing (RDON) said that she assisted with
Resident #1's discharge. She maintained that she
gave her a list of her medication, diagnoses, Care
Plan, and a summary of her stay. She said that
while she went through the discharge with
Resident #1, the Administrator poked her head in
the room. Resident #1 called her a "bitch" but did
not say why the Administrator upset her. She said
that Resident #1 did not share any concerns with
her and she had offered her other avenues to file
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grievance but she was not interested. She
maintained that they planned the discharge since
10/9/23. Resident #1 knew about it and agreed to
the transfer. She said that as they packed things
up, Resident #1 said that she thought that she
could only have 3 bags of items at the shelter, but
the SW disagreed with her, and said that they
would take all her things.
The Dependent Adult Abuse Protocols dated

November 2019, described the procedure for
keeping resident free from abuse include
screening and training employees, protection of
residents and prevention, identification,
investigation and timely reporting of abuse,
neglect, mistreatment, and misappropriation of
proper, without the fear of recrimination or
intimidation.
F 609 Reporting of Alleged Violations F 609
SS=J CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)
§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
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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.
by:
Based on clinical record review, facility policy
review, staff, and resident interviews, the facility
failed to report allegations of abuse within 2 hours
for 1 of 3 residents reviewed (Resident #1).
Resident #1 reported to staff on 10/23/23 that a
staff member sexually abused her, in addition to
transferring money from her account to staff. The
facility did not report the incident to the
appropriate authorities until the evening of
10/24/23.
Findings include:


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11/10/23.
needs of the resident welfare on 11/10/23.

pain.

dated 10/3/23:
to the community.
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use, and transfers.
front wheel walker.

she waited outside of the facility for a ride after
her shift and sat with Resident #1 on the patio.
Resident #1 told her that Staff I, Certified Nurse
Aide (CNA), bought her cigarettes, then he took
her phone and transferred money into his own
Cash App. After this, Resident #1 told Staff A that
he took her to his car one night and forced her to
perform oral sex on him. Resident #1 said that
they were drinking alcohol and she did not want
when Resident #1 told them that she had a video
from Staff I, but she needed to charge her phone,
so she could not show them. She said that
Resident #1 trembled when she told them the
story and expressed fear of what he might do if
he knew she told anyone.

evening of 10/23, Resident #1 sat outside with
Staff A and when she approached, Staff A looked
at her and asked "can I tell her?" Resident #1
shook her head "yes" and Staff A proceeded to
tell her that Staff I sent her a video of himself
masturbating. They agreed that they needed to
report this to the Administrator. The next morning
at around 10:00 AM they both went in to talk to
the Administrator.
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forced sexual acts.
The complaint unit from The Department of

Inspections, Appeals, and Licensing (DIAL)
confirmed in an email on 11/28/23 that the facility
reported the incident on 10/24/23 at 9:35 PM.
The Sheriff's Office Incident Report dated 11/1/23

at 6:22 PM, reflected that a Sheriff's Office
Representative interviewed Resident #1 about
allegations of sexual abuse. She said that during
her time as a resident in the nursing home, Staff
I, CNA, sexually abused her. She stated that
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while taking care of her, Staff I would touch and
kiss her inappropriately on the back of the neck
and on her feet. She said that 2-3 weeks prior to
her discharge, she went outside the facility to
have a cigarette and it had been raining. Staff I
asked if she would like to have her cigarette in his
car and she agreed. He wheeled her to the car
and while in the vehicle, he forced her to perform
oral sex on him. She described the vehicle as a
small red car parked by the row of trees near the
highway.

On 11/13/23 at 10:30 AM Staff P, Former Office

Manager, said that she no longer worked at the
facility. She felt that the administration was
looking for some reason to terminate her because
she questioned them on reporting the events to
the proper authorities. Staff P said that she heard
about the allegations of abuse later in the day on
10/24/23 and sent a text to the Regional Manager
at 5:30 PM, expressing that they should report the
event. She then she got a call back from
corporate that Resident #1 recanted the
allegations so they did not think they needed to
report it. She said that when she came into work
on the 25th, her office had been in shambles
because they were looking through for missing
orders. They suspended her because of the
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missing orders.

activity.

According to the facility policy titled; Mandatory

Reporting Abuse Investigation dated November
2019. All allegations of resident abuse need
reported immediately. Administrator or his/her
designee will designate a member of
management to investigate the alleged incident to
include: review of assessment of resident injury,
assess the resident for injury, provide notification
to primary care provider, and attempt to obtain
witness statements (oral and/or written) from all
known witnesses. The facility will establish and
enforce an environment that encourages
individuals to report allegations of abuse without
fear of recrimination (blame) or intimidation.
F 610 Investigate/Prevent/Correct Alleged Violation F 610
SS=J
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CFR(s): 483.12(c)(2)-(4)
§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.
by:
Based on interviews with residents, staff and law
enforcement, record review and policy review the
facility failed to adequately investigate allegations
of abuse for 1 of 3 residents reviewed (Resident
#1). After Resident #1 reported allegations of
sexual and financial abuse, the administration
only addressed the exchange of money but
minimized and failed to fully investigate the
allegations of sexual abuse.
Findings include:

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11/10/23.

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pain.

dated 10/3/23:
to the community.
use, and transfers.
front wheel walker.


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the Administrator.

perform oral sex on him. She said that he treated
her nice and spent time with her. She thought that
she may have gave him the wrong impression
when she sent him texts. He then sent her a
video of him pleasuring himself.

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forced sexual acts.
According to an untitled and undated facility

investigation, two staff members reported to the
Administrator that Resident #1 voiced concerns
about Staff I. She indicated that the concerns
were related to the purchase of cigarettes and
when Resident #1 went to Staff I's car to get
cigarettes, he made a gesture of oral sex while
outside his car. When asked about the incident,
Resident #1 denied that it occurred. The
investigation indicated that Resident #1 had a
history of making false stories and exaggerating
events to gain attention. The Administrator
separated Staff I from the facility and he admitted
to purchasing cigarettes for Resident #1. The
investigation statement included comments that
the staff member who reported the abuse, had a
history of making allegations against Staff I, and
that many staff and residents at the facility had a
history of making false allegations against African
Americans. The statement indicated the facility
contacted law enforcement on 10/24/23.
The investigation included an undated list of

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resident interviews, the investigation lacked staff
interviews, and a resident assessment.
On 11/14/23 at 8:47 AM a representative from the

sheriff's office went through the files to see if they
got any calls from the facility on 10/24 or 10/25
about possible abuse with Resident #1 as the
victim. The staff reported that they did not have
any calls from the facility regarding abuse
allegations.

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activity.

The Dependent Adult Abuse Protocols November

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2019 instructed that upon receiving a report of an
allegation of resident abuse, the facility shall
immediately implement measures to prevent
further potential abuse of residents from
occurring while the facility investigation is in
process. If this involves an allegation of abuse by
an employee, the facility will accomplish this by
separating the employee accused of abuse from
all residents through the following or a
combination of the following, if practicable: (1)
suspending the employee; (2) segregating the
employee by moving the employee to an area of
the facility where there will be no contact with any
residents of the facility
According to the facility policy titled; Mandatory

Reporting Abuse Investigation dated November
2019 directed that all allegations of resident
abuse need reported immediately. Administrator
or his/her designee will designate a member of
management to investigate the alleged incident to
include: review of assessment of resident injury,
assess the resident for injury, provide notification
to primary care provider, and attempt to obtain
witness statements (oral and/or written) from all
known witnesses. The facility will establish and
enforce an environment that encourages
individuals to report allegations of abuse without
fear of recrimination (blame) or intimidation. The
section titled Initial/Immediate Protection during
Facility Investigation instructed that Upon
receiving a report of an allegation of resident
abuse, the facility shall immediately implement
measures to prevent further potential abuse of
residents from occurring while the facility
investigation is in process. If this involves an
allegation of abuse by an employee, the facility
will accomplish this by separating the employee
accused of abuse from all residents through the
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following or a combination of the following, if
practicable: (1) suspending the employee; (2)
segregating the employee by moving the
employee to an area of the facility where there
will be no contact with any residents of the facility.
Following completion of the facility investigation, if
the facility concludes that the allegations of
resident abuse are unfounded, the employee will
be allowed to return to job duties involving
resident contact, but the employee must maintain
a separation and have no contact with the
resident alleged to have been abused, by
reassigning the accused employee to an area of
the facility where no contact will be made
between the accused employee and the resident
alleged to have been abused. The facility must
maintain the separation until the Department
concludes its investigation and issues the written
results of its investigation. Note: if the Department
of Inspections, Appeals, and Licensing (DIAL)
determines there was abuse (even though the
facility did not substantiate the abuse), there is
risk that DIAL could cite the facility with
Immediate Jeopardy, for allowing an abuser to
have access to other residents while the
investigation continued.
F 622 Transfer and Discharge Requirements F 622
SS=J CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)
§483.15(c) Transfer and discharge-

§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to
remain in the facility, and not transfer or
discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the
resident's welfare and the resident's needs
cannot be met in the facility;
(B) The transfer or discharge is appropriate
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because the resident's health has improved
sufficiently so the resident no longer needs the
services provided by the facility;
(C) The safety of individuals in the facility is
endangered due to the clinical or behavioral
status of the resident;
(D) The health of individuals in the facility would
otherwise be endangered;
(E) The resident has failed, after reasonable and
appropriate notice, to pay for (or to have paid
under Medicare or Medicaid) a stay at the facility.
Nonpayment applies if the resident does not
submit the necessary paperwork for third party
payment or after the third party, including
Medicare or Medicaid, denies the claim and the
resident refuses to pay for his or her stay. For a
resident who becomes eligible for Medicaid after
admission to a facility, the facility may charge a
resident only allowable charges under Medicaid;
or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the
resident while the appeal is pending, pursuant to
§ 431.230 of this chapter, when a resident
exercises his or her right to appeal a transfer or
discharge notice from the facility pursuant to §
431.220(a)(3) of this chapter, unless the failure to
discharge or transfer would endanger the health
or safety of the resident or other individuals in the
facility. The facility must document the danger
that failure to transfer or discharge would pose.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a
resident under any of the circumstances specified
in paragraphs (c)(1)(i)(A) through (F) of this
section, the facility must ensure that the transfer
or discharge is documented in the resident's
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medical record and appropriate information is
communicated to the receiving health care
institution or provider.
(i) Documentation in the resident's medical record
must include:
(A) The basis for the transfer per paragraph (c)(1)
(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this
section, the specific resident need(s) that cannot
be met, facility attempts to meet the resident
needs, and the service available at the receiving
facility to meet the need(s).
(ii) The documentation required by paragraph (c)
(2)(i) of this section must be made by-
(A) The resident's physician when transfer or
discharge is necessary under paragraph (c) (1)
(A) or (B) of this section; and
(B) A physician when transfer or discharge is
necessary under paragraph (c)(1)(i)(C) or (D) of
this section.
(iii) Information provided to the receiving provider
must include a minimum of the following:
(A) Contact information of the practitioner
responsible for the care of the resident.
(B) Resident representative information including
contact information
(C) Advance Directive information
(D) All special instructions or precautions for
ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a
copy of the resident's discharge summary,
consistent with §483.21(c)(2) as applicable, and
any other documentation, as applicable, to ensure
a safe and effective transition of care.
by:
Based on clinical record review, interviews with
staff and residents and policy review the facility
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failed to meet a resident's needs related to
adequately planned transfers for 1 of 3 residents
reviewed (Resident #1). The facility discharged
Resident #1 abruptly after allegations of abuse to
a homeless shelter that did not know of her
transfer. The homeless shelter did not have
nurses on staff to meet her medical needs and
they did not have any staff overnight. The
homeless shelter transferred Resident #1 to the
hospital as she could not safely remain in the
homeless shelter. After arriving to the homeless
shelter, Resident #1 began to stumble and fall.
Findings include:


11/10/23.
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pain.

dated 10/3/23:
to the community.
use, and transfers.
front wheel walker.

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so her son could come and live with her. The SW
offerred a homeless shelter as option but her son
could not go there due to his age. She said she

added the following to Resident #1's Care Plan:
building smoking.


conclusion.

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not talk about the abuse allegations.


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the shelter.


on Friday or Monday. She questioned about he
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On 11/14/23 at 12:12 PM a representative for the

transportation company said that they usually only
offer the 4-hour pickup option for an emergency;
such as going to hospital or an important
appointment, but they usually did a 48-hour
pickup.

Nurse (RN), said that on the morning of the
discharge the Administration rushed her to get a
7-day supply of medications prepared to send
with Resident #1. Early that morning, Resident #1
#1 expressed that she felt like the facility was
kicking her out. Staff N said that she understood
that they had a plan for discharge but it came
very abruptly. Staff N reported she had concerned
without nursing services especially when the
provider just changed her hypertension
medication that needed monitoring.
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fact that no one talked to Shelter Staff 2 (SS2)
"that SW lady."

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of that. Staff 2 started the intake and later called
on their own. Staff 2 said if Resident #1 stayed
The Encounter Note dated 10/24/23 at 12:00 AM

signed by the Advanced Registered Nurse
Practitioner (NP) on 10/26/23 at 8:08 PM
reflected that Resident #1 saw the NP on
10/24/23. At that time, Resident #1 cried and
stated that she had a lot of pain. They discussed
getting her an appointment with the pain clinic.
Resident #1 told her about her leaving the facility
in 1-2 days, as the staff falsely accused her of
being inappropriate with a staff member. She
planned to leave and be at the homeless shelter
for 6 months. The provider received a call from
the facility on 10/25/23 indicating that day they
planned to discharge Resident #1. The NP
recommended to follow-up for medication refills in
six months and she would provide a 7-day supply
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of medications.
The Blood Pressure Summary and Pulse (HR, an

elevated pulse is over 100) Summary reviewed
on 11/9/23 included the following results (low
blood pressure considered to be below 90/60):
a. 10/17/23 at 4:14 PM 89/60, HR 112
b. 10/18/23 at 3:17 PM 96/62
c. 10/19/23 at 2:23 PM 84/55 HR 112
The Communication - With Physician Note dated

10/24/23 at 4:33 PM reflected the NP came to the
facility and wrote the following new orders:
a. Discontinue clonidine (hypertension medicine)
b. Discontinue Coreg (hypertension medicine)
c. Start Metoprolol 25 MG (hypertension medicine
that lowers pulse)
d. Complete lipids, complete blood count (CBC),
comprehensive metabolic panel (CMP), thyroid
stimulating hormone (TSH), and a hemoglobin
A1C (lab test that measure your blood sugars
over three months) labs, then repeat in 6 months.
A prescription dated 10/24/23 at 4:22 PM

returned from the pharmacist noting that
discontinuation of clonidine should not happen
abruptly. Please consider tapering gradually and
monitor for rebound hypertension.
The Communication - With Physician Note dated

10/25/23 at 2:09 AM indicated that the Pharmacy
faxed that discontinuation of clonidine should not
happen abruptly due to rebound hypertension
(withdrawal syndrome that occurs when
discontinuing antihypertensive drugs abruptly,
leading to a rapid increase in blood pressure
without symptoms). The facility notified the NP via
fax.
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The Nurses Note dated 10/25/23 at 10:58
indicated the facility received a telephone order
from the NP to discharge with current medication
and treatment orders to the homeless shelter.
The Orders - Administration Note dated 10/25/23

at 10:02 AM indicated that Resident #1 did not
receive her dressing change or lab work because
she discharged home.
The Discharge Summary dated 10/25/23 at 12:00

PM identified that Resident #1 discharged to the
homeless shelter on 10/25/23. Resident #1
refused to provide a primary care physician or a
preferred pharmacy upon discharge. She gave
verbal agreement of an accurate account of her
items at discharge. The facility notified Resident
#1's Case Worker and lawyer of her discharge.
The Order Note dated 10/25/23 at 1:59 PM, the

NP gave a new order to decrease clonidine to 0.1
mg daily instead of discontinuing.
On 11/14/23 at 10:04 AM the Pharmacist reported

a clinical concern of an increased risk of rebound
hypertension with an abrupt stop of clonidine. The
Pharmacist recommended a titrated decrease
with monitoring. She said that with an abrupt stop
to the medication she would recommend twice a
day blood pressure monitoring.
The Clinical Physician's Orders listed the

clonidine 0.2 milligrams twice daily as
discontinued on 10/24/23.

Nurse (RN), said that if the NP discontinued the
medication on 10/24/23, she would not have
included it with the 7-day supply.
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On 11/13 at 1:39 PM The Director of Nursing

(DON) stated that she could not find a copy of the
list of medications that went with the resident
upon discharge.

11/15/23 at 11:08 AM The Director of Nursing

(DON) said that she did not know that they
discontinued Resident #1's abruptly and that the
pharmacy recommended not to stop the medicine
abruptly. She agreed that Resident #1's blood
pressure (BP) needed monitoring after the
medication change. She did not assist with the
discharge due to her not being available when all
the discharge activity and decisions happened.
She said that she did not know if anyone
consulted nursing to see about any reason why
they should delay Resident #1's discharge.
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According to the Discharge Summary dated
10/25/23 the most recent vital signs included in
the summary included a blood pressure taken on
10/19/23 at 84/55 and a pulse of 112 beats per
minute.
On 11/16/23 at 10:58 AM Staff D said that they

consulted her with the discharge planning for
Resident #1 and that she knew about going to the
homeless shelter. She did not know about the
change in medication or the recommendation
from pharmacy to follow up with blood pressure
(BP) monitoring. She said that ideally, she would
have liked to see a set of vitals on the day of
discharge. If the Resident #1 status had
concerns, they would arrange for a follow-up with
the receiving entity. She maintained that the
facility did a well-planned and safe discharge.
With BP concerns, perhaps a BP cuff would have
been appropriate for the resident to use. She said
that the resident was aware enough to manage
her health needs but when there were medication
changes close to discharge it can be concerning.
When asked why the facility rushed to discharge
Resident #1 or why they did not wait to monitor
her for a couple of days, Staff D expressed that
they did not rush the discharge. She added that
the transportation arrangements made it seem
that way, but they could not control that.
The Transfer or Discharge Documentation policy

revised December 2016 directed that if a resident
transferred or discharged, the facility must
document the details of the transfer or discharge
in the medical record, and communicate
appropriate information to the receiving health
care facility or provider.
The facility may initiate transfer or discharge for
the following: a. Necessary for the resident's
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welfare and the facility cannot meet their needs.
b. The resident's health improved significantly so
that the resident no longer needs the care or
services.
c. The resident's clinical or behavioral status
endangered the safety of individuals in the facility.
d. The resident's clinical or behavioral status
endangers the health of individuals in the facility.
e. The resident failed to pay after reasonable and
appropriate notice.
f. Facility ceases to operate.
F 660 Discharge Planning Process F 660
SS=D CFR(s): 483.21(c)(1)(i)-(ix)
§483.21(c)(1) Discharge Planning Process

The facility must develop and implement an
effective discharge planning process that focuses
on the resident's discharge goals, the preparation
of residents to be active partners and effectively
transition them to post-discharge care, and the
reduction of factors leading to preventable
readmissions. The facility's discharge planning
process must be consistent with the discharge
rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each
resident are identified and result in the
development of a discharge plan for each
resident.
(ii) Include regular re-evaluation of residents to
identify changes that require modification of the
discharge plan. The discharge plan must be
updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined
by §483.21(b)(2)(ii), in the ongoing process of
developing the discharge plan.
(iv) Consider caregiver/support person availability
and the resident's or caregiver's/support
person(s) capacity and capability to perform
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required care, as part of the identification of
discharge needs.
(v) Involve the resident and resident
representative in the development of the
discharge plan and inform the resident and
resident representative of the final plan.
(vi) Address the resident's goals of care and
treatment preferences.
(vii) Document that a resident has been asked
about their interest in receiving information
regarding returning to the community.
(A) If the resident indicates an interest in returning
to the community, the facility must document any
referrals to local contact agencies or other
appropriate entities made for this purpose.
(B) Facilities must update a resident's
comprehensive care plan and discharge plan, as
appropriate, in response to information received
from referrals to local contact agencies or other
appropriate entities.
(C) If discharge to the community is determined
to not be feasible, the facility must document who
made the determination and why.
(viii) For residents who are transferred to another
SNF or who are discharged to a HHA, IRF, or
LTCH, assist residents and their resident
representatives in selecting a post-acute care
provider by using data that includes, but is not
limited to SNF, HHA, IRF, or LTCH standardized
patient assessment data, data on quality
measures, and data on resource use to the extent
the data is available. The facility must ensure that
the post-acute care standardized patient
assessment data, data on quality measures, and
data on resource use is relevant and applicable to
the resident's goals of care and treatment
preferences.
(ix) Document, complete on a timely basis based
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on the resident's needs, and include in the clinical
record, the evaluation of the resident's discharge
needs and discharge plan. The results of the
evaluation must be discussed with the resident or
resident's representative. All relevant resident
information must be incorporated into the
discharge plan to facilitate its implementation and
to avoid unnecessary delays in the resident's
discharge or transfer.
by:
Based on clinical record review, interviews with
staff and residents and policy review the facility
failed to meet a resident's needs related to
discharge planning for 1 of 3 residents reviewed.
Resident #1 was discharged abruptly after
allegations of abuse and was sent to a homeless
shelter that was unaware that she was coming
and could not meet her medical needs. The
facility reported a census of 30 residents.
Findings include:

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pain.

dated 10/3/23:
to the community.
use, and transfers.
front wheel walker.
A Social Service note dated 10/10/23 indicated

that the Social Worker met with Resident #1's
Case Worker and Resident #1. The discussion
included that Resident #1 had no family support.
Resident #1 claimed her youngest son as her
only advocate. The conversation listed two
different options as discharge options, but
Resident #1 preferred the homeless shelter as
she had a better chance with reuniting with her
son. The note lacked a planned date for
discharge.

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so her son could come and live with her. The SW
offerred a homeless shelter as option but her son
could not go there due to his age. She said she

the shelter.

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on Friday or Monday. She questioned about her

On 11/14/23 at 12:12 PM a representative for the

transportation company said that they usually only
offer the 4-hour pickup option for an emergency;
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such as going to hospital or an important
appointment, but they usually did a 48-hour
pickup.

Nurse (RN), said early that morning, Resident #1
#1 expressed that she felt like the facility kicked
her out. Staff N said that she understood that they
had a plan for discharge but it came very
abruptly. Staff N reported that she had concerns
without nursing services especially when she
needed monitoring as the provider just changed
her hypertension medication.


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fact that no one talked to Shelter Staff 2 (SS2)
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"that SW lady."

of that. Staff 2 started the intake and later called
on their own. Staff 2 said if Resident #1 stayed
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On 11/15/23 at 11:08 AM The Director of Nursing

(DON) said that she did not know that they
discontinued Resident #1's abruptly and that the
pharmacy recommended not to stop the medicine
abruptly. She agreed that Resident #1's blood
pressure (BP) needed monitoring after the
medication change. She did not assist with the
discharge due to her not being available when all
the discharge activity and decisions happened.
She said that she did not know if anyone
consulted nursing to see about any reason why
they should delay Resident #1's discharge.
The Transfer or Discharge Documentation policy

revised December 2016 directed that if a resident
transferred or discharged, the facility must
document the details of the transfer or discharge
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in the medical record, and communicate
appropriate information to the receiving health
care facility or provider.
F 835 Administration F 835
SS=E CFR(s): 483.70
§483.70 Administration.
A facility must be administered in a manner that
enables it to use its resources effectively and
efficiently to attain or maintain the highest
practicable physical, mental, and psychosocial
well-being of each resident.
by:
Based on interviews and record review the
facility failed to ensure they provided adequate
administration services. Upon allegations of
abuse, the administrator failed to conduct a
thorough investigation, failed to report the
allegations to the proper authorities, and abruptly
discharged the resident who made the allegation
(Resident #1). The facility reported a census of
30 residents.
Findings include:

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pain.


the Administrator.

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forced sexual acts.
The Care Plan Focus dated 10/3/23 reflected that

Resident #1 planned to rehab to home. The Goal
listed that Resident #1 would transition back to
the community.
According to an untitled and undated facility

investigation, two staff members reported to the
Administrator that Resident #1 voiced concerns
about Staff I. She indicated that the concerns
were related to the purchase of cigarettes and
when Resident #1 went to Staff I's car to get
cigarettes, he made a gesture of oral sex while
outside his car. When asked about the incident,
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Resident #1 denied that it occurred. The
investigation indicated that Resident #1 had a
history of making false stories and exaggerating
events to gain attention. The Administrator
separated Staff I from the facility and he admitted
to purchasing cigarettes for Resident #1. The
investigation statement included comments that
the staff member who reported the abuse, had a
history of making allegations against Staff I, and
that many staff and residents at the facility had a
history of making false allegations against African
Americans. The statement indicated the facility
contacted law enforcement on 10/24/23.
The investigation included an undated list of

resident interviews, the investigation lacked staff
interviews, and a resident assessment.
On 11/14/23 at 8:47 AM a representative from the

sheriff's office went through the files to see if they
got any calls from the facility on 10/24 or 10/25
about possible abuse with Resident #1 as the
victim. The staff reported that they did not have
any calls from the facility regarding abuse
allegations.

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activity.

According to an annual facility survey report

dated 10/19/22, Staff I recorded a resident
without her consent or knowledge. His personal
file lacked a corrective action form or any
indication that the facility addressed that incident
with him.
Staff I's timesheet showed that he continued to

work with vulnerable elderly population in their
facilities on 10/24/23 from 2:04 PM - 7:02 PM,
10/28/23 from 10:19 PM - 6:14 AM, and on
10/30/23 at 10:01 PM - 6:00 AM.
The Facility's Job Description for the position of

Administration revised April 2018, described the
Essential Functions for General Management as
to operate the facility in accordance with the
established company policies and procedures in
compliance with federal, state and local
regulations. They would assume responsibility for
notifying appropriate state and local agencies of
transfer either temporary or permanent. They
assure that staff implements programs and
services to assess and meet the health and
psychosocial needs of the residents.
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Report

Uploaded by

Report

Uploaded by

PRINTED: 12/07/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 000 INITIAL COMMENTS F 000

Correction date: __________________

The Correctionville Specialty Care Nursing Home

Findings for complaints #116629-A and 116630-A

§483.12 Freedom from Abuse, Neglect, and

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 1 F 600

The State Agency informed the facility of the

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 2 F 600

Resident #1's Minimum Data Set (MDS)

The Care Plan included the following Focuses

The Discharge Summary note dated 10/25/23 at

The Sheriff's Office Incident Report dated 11/1/23

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 3 F 600

On 11/14/23 at 2:15 PM, the Police Officer who

On 11/6/23 at 2:13 PM, Resident #1 said that

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 4 F 600

When asked to share the sexually explicit video

On 11/15/23 at 2:20 PM, Resident #1 said that

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 5 F 600

Resident #1's Clinical Physician's Orders

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 6 F 600

A review of the weather history indicated that it

Timesheet records show that Staff I worked on

Resident #1's text messages revealed that she

On 11/16/23 at 8:56 AM Staff F admitted that she

On 11/8/23 at 10:48 AM, Staff A, Dietary Aide

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 7 F 600

On 11/8/23 at 10:32 AM, Staff F said that on the

On 11/8/23 at 2:18 PM, the Administrator said

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 8 F 600

A hand-written note dated 10/24/23 at 8:52 AM,

On 10/24/23, the Regional MDS Coordinator (RC)

According to a Social Services Behavior History

The follow-up Behavioral History completed on

On 11/13/23 at 8:47 AM the RC described her

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 9 F 600

On 11/13/23 at 9:00, Staff D, Registered Nurse

On 11/6/23 at 1:33 PM, Staff J, NA, said that

On 11/6/23 at 1:38 PM Staff K, CNA, said that

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 10 F 600

On 11/8/23 at 11:55 AM, Staff M, CNA, said she

On 11/8/23 at 8:17 AM, Staff E, Registered Nurse

On 11/8/23 at 3:30 PM, Staff Q, CNA, said that

On 11/9/23 at 8:50 AM, Staff I said that on

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 600 Continued From page 11 F 600

1116 EAST HIGHWAY 20

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)