CoMwsSSONBI. Jon Weizenbaum Dear Nursing Facility Administrator, Please ensure the facility's Plan of Correction (PoC) addresses all five of the following criteria: CRITERION #1 How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Plan of Correction must include what materials and/or methods were used to correct the issue. CRITERION #2 How other residents with the potential to be affected by the same deficient practice will be identified. CRITERION #3 What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur. CRITERION #4 How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur; i.e., what program will be put into place to monitor the continued effectiveness of the system changes. CRITERION #5 When the corrective action will be completed. Completion dates must be acceptable to DADS. You are required to record your PoC in the appropriate column on forms DADS-3724 and CMS-2567; Sign, date, and indicate your title in the blocks provided on page one of the forms. When both licensure violations and certification deficiencies are cited, the PoC must be submitted by the tenth (10th) calendar day from your receipt of the forms. Return the forms with the PoC to your program manager. Failure to submit an acceptable PoC by the due date may result in facility receiving an Unacceptable POC Letter, which includes the following statement: Failure to submit acceptable PoCs by (Date) may result in notice of immediate termination of your facility's provider agreement. [42 CFR §488.456(b)(ii)] If you have questions about how to write your PoC a FREE computer-based training (CBT) course "Writing Acceptable Plans of Correction" is available for your facility type at the following website: http://www.dads.state.tx.us/providers/training/index.cfm If you have any questions about your PoCs, feel free to call me at 512-908-9676. Thanks, Program Manager - Region 7 Department of Aging and Disability Services 701 W. 51st St. * P.O. Box 149030 * Austin, Texas 78714-9030 * (512) 438-3011 An Equal Opportunity Employer and Provider * www.dads.state.tx.us Commissioner Jon Weizenbaum Regulatory Services Division Central Texas Region (7) 4501 S General Bruce Dr., Suite 25 Temple, Texas 76502-1466 (254) 742-2955 April 17, 2017 ELECTRONIC MAIL Administrator Windsor Nursing And Rehabilitation Center Of Duval Provider #: 675956 Facility ID #:004970 5301 W Duval Rd Austin TX 78727 Type: SNF/NF Dear Administrator: On March 31, 2017, the Department of Aging and Disability Services (DADS) conducted a Health Survey, to determine if your facility complies with state licensure requirements and federal participation requirements for nursing facilities in the Medicare or Medicaid (or both) programs. This survey found that your facility does not meet state licensure requirements and is not in substantial compliance with federal participation requirements. References to state statutory requirements contained in this letter are found in Chapter 242 of the Health and Safety Code. Federal regulatory requirements referenced in this letter are found in Title 42, Code of Federal Regulations (CFR). PLAN OF CORRECTION (POC) You must submit a plan of PoC for the licensure violations recorded on the enclosed DADS Form 3724 and certification deficiencies recorded on the enclosed Form Centers for Medicare and Medicaid Services (CMS)-2567. When both licensure violations and certification deficiencies are cited, the PoC must be submitted by the tenth (toth) calendar day from your receipt of this letter. Your PoC must contain the following: • What corrective action will be taken for those residents found to have been affected by the deficient practice; • How other residents with the potential to be affected by the same deficient practice will be identified; • What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; 701 W. 51 st St. * P.O. Box 149030 * Austin, Texas 78714-9030 * (512) 438-3011 * www.dads.state.tx.us An Equal Opportunity Employer and Provider Administrator Windsor Nursing And Rehabilitation Center Of Duval, Austin April 17, 2017 Page 2 • How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur; i.e., what program will be put into place to monitor the continued effectiveness of the system changes; and • When corrective action will be completed. Completion dates must be acceptable to DADS. You are required to record your plan of correction in the appropriate column on the enclosed DADS Form 3724 and Form CMS-2567. Sign, date, and indicate your title in the blocks provided on page one of the forms. Return the forms mail, email or fax with POCs to: Ms. Joelle Henao, Program Manager, 10205 North Lamar Blvd., Second Floor (MC 018-7), Austin, Texas, 78753-3658, (ph. #) 512-908-9676, (fax#) 512-908-9615. Failure to submit an acceptable PoC for certification deficiencies on Form CMS-2567 by the due date may result in termination of your provider agreement [42 CFR §488.456(b)(ii)]. If applicable, other certification deficiencies recorded on the CMS-A Form do not require a PoC [42 CFR §488.402 (d)(2)]. Your facility is expected to correct and maintain correction of all deficiencies/violations. Termination of your provider agreement will be effective on date October 1, 2017, if substantial compliance is not achieved by that time [42 CFR §488.456]. Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement listed above. Should the CMS Dallas Regional Office or the State Medicaid Agency determine that termination of your provider agreement or any other remedy is warranted, CMS or the State Medicaid Agency will provide you with a separate formal notice of that determination. NOTICE OF STATUTORY DENIAL OF PAYMENT FOR NEW MEDICARE AND MEDICAID ADMISSIONS If you do not make substantial corrections to the deficiencies cited within three (3) months of the last day of the survey, the CMS Regional Office or State Medicaid Agency will deny payments for new (Medicare/Medicaid) admissions [42 CFR §488.417(b)(l)]. Based on deficiencies cited during this survey and as authorized by the CMS Dallas Regional Office, the State Agency is giving formal notice of imposition of statutory Denial of Payment for New Admissions [42 CFR §488.417(b)(l)] effective July 1, 2017. This remedy will be effectuated on the stated date unless you demonstrate substantial compliance with an acceptable plan of correction and subsequent revisit. This notice in no way limits the prerogative of CMS or the State Medicaid Agency to impose discretionary DPNA at any appropriate time. CMS Regional Office will notify your intermediary and the State Medicaid Agency of Administrator Windsor Nursing And Rehabilitation Center Of Duval, Austin April 17, 2017 Page 3 imposition. If effectuated, denial of payment will continue until your facility achieves substantial compliance or your provider agreement is terminated. [Facilities are prohibited from billing those Medicare/Medicaid residents or their responsible parties during the denial period for services normally billed to Medicare or Medicaid.] The Medicare and Medicaid programs will make no payment for residents whose plans of care begin on or after the DPNA effective date. REFER TO THE APPEAL RIGHTS INCLUDED IN THIS LETTER. YOU MAY APPEAL THE FINDING OF NONCOMPLIANCE THAT LED TO THE REMEDY, BUT NOT THE REMEDY ITSELF. LICENSURE ACTIONS Based on the licensing violations cited during this survey, we are recommending that the following action(s) be taken, pursuant to Chapter 242 of the Health and Safety Code (H&SC): • Administrative Penalties [H&SC §242.066]. instructions on how to request a hearing. Refer to attached DADS Form 3719 for Please note that this notice does not constitute formal notice of imposition of the licensure action(s). Unless stated differently above, if DADS imposes the licensure action(s), State Office sends you a separate, written notice that includes your appeal rights. ALLEGATION OF COMPLIANCE The plan of correction serves as your allegation of compliance until substantiated by a revisit. If, upon the subsequent revisit, your facility has not made substantial corrections to the deficiencies cited during this survey, we will recommend that remedies previously mentioned in this letter be imposed by the CMS Regional Office or State Medicaid Agency, and continue until substantial compliance is achieved. In addition, the CMS Regional Office or State Medicaid Agency may impose revised remedies based on changes in the seriousness of the noncompliance at the time of the revisit, as appropriate. INFORMAL DISPUTE RESOLUTION You may contest cited licensure violations and certification deficiencies through the informal dispute resolution (IDR) process [42 CFR §488.331 and 40 TAC §19.2147]. Guidelines and procedures to request an IDR, as well as the IDR Request Form, are available at the following Health and Human Services Commission (HHSC) website: https://hhs.texas.gov/doing-business-hhs/vendor-contractor-information/informal-dispute-r esolution-process. An IDR Request form must be completed and faxed to HHSC within ten (10) calendar days of your facility receiving the statement of violations. Complete and fax the IDR Request form to: Health and Human Services Commission, IDR Program, 1106 Clayton Lane, Suite 300 W, Austin, TX 78723, Fax (512) 706-7275. Administrator Windsor Nursing And Rehabilitation Center Of Duval, Austin April 17, 2017 Page 4 You must also fax a copy of the IDR Request form to the regional DADS office at: Texas Department of Aging and Disability Services, ATTN: Mr. Michael Lanham, Compliance Reviewer, 4501 S. General Bruce Dr., Suite 25, Temple, Texas, 76502-1466, {ph #) 254-742-3802, (fax#) 254-742-3890. APPEAL RIGHTS FOR MEDICARE-ONLY OR DUALLY-CERTIFIED FACILITIES If you disagree with this action imposed on your facility, you or your legal representative may request a hearing before an administrative law judge of the Department of Health and Human Services, Departmental Appeals Board (DAB). Procedures governing this process are set out in 42 C.F.R. 498.40, et seq. You must file your hearing request electronically by using the Departmental Appeals Board's Electronic Filing System (DAB E-File) at https://dab.efile.hhs.gov no later than June 16, 2017. Specific instructions on how to file electronically are attached to this notice. A copy of the hearing request shall be submitted electronically to: Marcus Foster marcus.foster@cms.hhs.gov Requests for a hearing submitted by U.S. mail or commercial carrier are no longer accepted as of October 1, 2014, unless you do not have access to a computer or internet service. In those circumstances you may call the Civil Remedies Division to request a waiver from e-filing and provide an explanation as to why you cannot file electronically or you may mail a written request for a waiver along with your written request for a hearing. A written request for a hearing must be filed no later than June 16, 2017, by mailing to the following address: Department of Health & Human Services Departmental Appeals Board, MS 6132 Director, Civil Remedies Division 330 Independence Avenue, S.W. Cohen Building-Room G-644 Washington, D.C. 20201 (202) 565-9462 A request for a hearing should identify the specific issues, findings of fact and conclusions of law with which you disagree. It should also specify the basis for contending that the findings and conclusions are incorrect. At an appeal hearing, you may be represented by counsel at your own expense. If you have any questions regarding this matter, please contact Marcus Foster by phone at 214-767-6456 or email at marcus.foster@cms.hhs.gov. If you have any questions, please contact Ms. Joelle Henao, Program Manager, 10205 North Administrator Windsor Nursing And Rehabilitation Center Of Duval, Austin April 17, 2017 Page 5 Lamar Blvd., Second Floor (MC 018-7), Austin, Texas, 78753-3658, (ph. #) 512-908-9676, (fax #) 512-908-9615. Sincerely, Elizabeth Thomas, Regional Director Regulatory Services Division, Region 7 ET:jmc Attachments DADS Notice of Accepted Plan of Correction (10/07) Texas Department of Aging and Disability Services Notice of Accepted Plan of Correction (Note: Acceotance of a plan of correction does not oreclude DADS from takinci enforcement action.l To: Facility Name Windsor Nursinq And Rehabilitation Center Of Duval Address 5301 W Duval Rd City I State TX Austin I Zip Code 78727 Telephone Number: (512)345-1805 Fax Number: (512)231-1976 Survey Date 03/31/2017 Provider Type SNF/NF Facility ID # 004970 Provider# 675956 From: Name: Joelle Henao Program: DADS Reqion 07 - North Austin Regional Office Address: 10205 N Lamar Blvd City: I State: Texas Austin Your plan of correction has been accepted for: _ Health Survey - Federal Deficiencies _ Health Survey - State Violations I Zip Code: 78753 _ _ Position: Proqram Manaqer Telephone Number: 512/908-9656 Fax Number: 512/908-9615 Mail Code: 018/7 Life Safety Code Survey - Federal Deficiencies Life Safety Code Survey - State Violations ALF, ADC, and HCSSA Follow-up Visit Information: DADS will not accept submission of documentation demonstrating correction of the violations/deficiencies cited as the sole indication by the licensee of compliance with the rules or regulations. DADS will verify compliance with the rules or regulations through an on-site inspection. NF Follow-up Visit Information: (Select only the statements that apply.) _ A first on-site revisit may be scheduled to determine compliance for violations/deficiencies cited. _ A second on-site revisit may be scheduled to determine compliance for violations/deficiencies cited. __ A third on-site revisit, if authorized, may be scheduled to determine compliance for violations/deficiencies cited. _L The plan of correction and/or evidence of compliance may be accepted as determination of correction in lieu of conducting an on-site follow-up visit. A desk review may be performed. If, during a future visit, violations or deficiencies that were considered corrected through a desk review are discovered not to have been corrected, enforcement actions may be recommended. _ We request evidence showing how the facility attained and maintains corrective action for the following violation(s)/deficiency(ies) cited on the exit date referenced above: __ This evidence must be received at the DADS regional office listed above by_ . The evidence must clearly identify to which violation/deficiency it corresponds. Examples of acceptable evidence of compliance include the following: • An invoice or receipt verifying purchases were made, repairs were completed, etc. • A photo of a corrected environmental issue. • A policy and procedure reflecting compliance and how compliance will be monitored and maintained. • A resident's care plan addressinq the comoliance issue. If you have questions, please contact the reaional office listed above. Signed: , ~ I Date: .s-\1-\,1 DEPARTMENT Of HEALTH A N D ~ SERVilCES CENTERS FOR MEDlCARE & r~EDllCAID SERVllCES ST.,T, I AUSTIN, TX 71ITZT ID PREFlX TAG ~A.MllOF~ {Elai~A01!0!~SHIOO!Wl!l!E Cift0SS-~il0EDT011'l£~'-1E OEF:ICBC<) Disclaimer; Preparation and execution of thls F 000 INITIAL COMMENTS F 000 plan of correction does not constitute admissiion i Ii or agreement of guilt by the provider of t!;,e truth of the farts alleged in the rondusions of !be statement of deficiencies.. The p!an of correction was conducted on 03/29/17 to 03/31/17 at Windsor Nursing and Rehabilit.ation Center of Duval. The 1facility census was 193. is prepared and executed so!ety because it is A complaint and incident im,estigation (#TX00257003, #TX00257052, and #TX00257279) I I F 164 483.10(h){1)(3)(i); 483.70(i)(2) PERSONAL SS=E ! PRIVACY/CONFIDENTIALITY OF RECORDS I1 F 164 F 164-Personal Privacy/Confidentiality 1. (i) The resident has the right to refuse the release of i personal and medical records except as provided at §483.70{i)(2) or other applicable federal or state laws. Resident #6 was assessed by the Director of Nursing 03/27/17. No evidence abuse, neglect, or adverse outcome noted 2. How other residents having the potential to be affected by the same deficient practice will be identified? • An audit of observation, staff. family, and resident interview and record review was conducted 03/27/17 by Nursing and Administration for all residents. No other residents were identified by this deficient practice. ~ C, >- c:c :;;: c::i UJ > 0 a:: (ii) Required by Law; What corrective action will be accomplished for those residents found to have been affected by the deficient practice? • (h)(3)The resident has a right to secure and confidential personal and medical records. (i) To the individual, or their resident representative where permitted by applicable law; 04/17/17 req"Jired by the pro'lisions of the federal law. 483.10 (h)(I) Personal privacy indudes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident §483.70 (i) Medical records. (2) The facility must keep confidential all infonnation contained in the resident's records, regardless of the form or storage method of the records, except when release is- t 5301WDUVALRD a... a... <( Tl~ Any deficien statement ending with an asterisk (•) de tes a deficiency which the institution may be excused from correcting providing it is determined that oth safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date or survey whether or not a plan or 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 EventlO: OU1 Y11 Facility 10: 4970 Page 1 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 0MB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION C 03/31/2017 B WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING AUSTIN, TX 78727 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE Disclaimer; Pre12:aration and execution of this F 000 INITIAL COMMENTS F 000 04/173()/ plan of correction does not constitute admission I or agreement of guilt bl'. the 12:rovider of the truth of the facts alleged in the conclusions of the A complaint and incident investigation (#TX00257003, #TX00257052, and #TX00257279) was conducted on 03/29/17 to 03/31 /17 at Windsor Nursing and Rehabilitation Center of Duval. The facility census was 193. statement of deficiencies. The plan of correction is prepared and executed so!Ply because it is required by the provisions of the federal law. F 164 f 164 ;.Personal Privacy[Co~fidentiality. - - - - - - - - F 164 483.1 O(h)(1 )(3)(i); 483.70(i)(2) PERSONAL SS=E PRIVACY/CONFIDENTIALITY OF RECORDS 1. 483.10 (h)(I) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. What corrective action will be - accomQlished for those residents found to have been affected by the deficient Qractice? Resident 116 was assessed by the Director of Nursing 03l27Ll7. No evidence abuse, neglect, or adverse outcome noted ~ ·- - - - - '," ,- i Formatted: Font: 10 pt, Bold -- , '" i~---------------~ Formatted: Left, Indent: Left: O" \ '~, i Formatted: Font: Bold ', i Formatted: Font: 10 pt .\ ~---------------~ i Formatted: Left 'i Formatted: Left, Tab stops: Not at 0.63" • (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. \ \ . (h)(3)The resident has a right to secure and confidential personal and medical records. ~ _ - -{ Formatted: Font: 10 pt, Bold - - -{ Formatted: Left 2. How other residents having the QOtential to be affected by the same deficient wactice will be identified? • An oudit of ohservotion. staff familv. and resident interview and record review was conducted 0'1,/27/17 h:,: Nursino and Administrntion for oll residents. No other residents were id~ntified hv this deficient practice. §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; •- - - -{ Formatted: Space After: 0 pt • - - - -{ Formatted: Justified (X6) DATE TITLE LABORATORY DIRECTOR'S OR PAOVIDEP/SUPPLIER REPRESENTATIVE'S SIGNATURE n 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 to: OU1 Y11 - ---- Facility ID: 4970 ------- - - --- -· ---- Page 1 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER~ FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2J MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 8. WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4J ID PREFIX TAG 03/31/2017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 1 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 164 (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (XS) COMPLETION DATE 3. What measures will be put into or what place Formatted: Indent: Left: 0.5'', Space After: O pt, Line spacing: single systematic changes will be made to ensure that the deficient practice does not occur. (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. This REQUIREMENT is not met as evidenced by: Formatted: Indent: Left: 0.5'', Space After: O pt, Line spacing: single -Training was 12rm·ided hv Facilitv Administrator, DON, Formatted: Left, Indent: Left: 0.5'', Space After: 6 pt, Line spacing: single and Nursing l\Tanagernent on 3/27/2017 a, re-education on the following areas: •-----------------Based on observation, interview, and record review, the facility failed to ensure personal privacy during personal care for one (1) of six (6) residents who resided on hall when: • Dignit',', Privac',', ------ Prohibition Abuse Policies, and Policies on Cell Phone Use and Social Media. Certified Nursing Aide (CNA) D posted three (3) photos of Resident #6 on his Snap Chat account (social media) while providing care to the resident. The photos of Resident #6 revealed she had a brown-like substance that appeared to be dried feces on her hand, when her nose was intentionally tickled with an object, and the Resident touched her face with her soiled hand. educated ugholding Formatted: Indent: Left: 0.63", Space After: Opt, Line spacing: single re- • Administrator staff on and gromoting Resident's Rights established b',' law in the course of gerforming their job This deficient practice could result in a loss of personal privacy during care for the 27 residents who resided on hall duties. Findings included: Review of Resident #6's Face Sheet, dated reflected the Resident was an year old female who was admitted the facility on Further review reflected Resident #6 had current diagnosis of FORM CMS-2567(02-99) Previous Versions Obsolete Event 1D:OU1Yt1 ~ _ - -{ Formatted: Font: Times New Roman Personal Abuse, Facility 10: 4970 Page 2 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 0MB NO 0938 -0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A BUILDING C B WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG 03/31/2017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 2 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 164 (XS) COMPLETION DATE 4.How the corrective action[s} will be monitored to ensure the deficient 11ractice is being corrected and will not recur, i.e., what 11rogram will Review of Resident #6's Quarterly Minimum Data Set (MOS), dated , reflected the Resident's Brief Interview for Mental Status (SIMS) score was a 2 (0-7), representing severe impairment Further review reflected Resident #6 was frequently incontinent of bowel and bladder, and required one person physical and extensive assist for toileting. be 11ut into place to monitor the continued effectiveness of the S'lstematic changes? • The Social Workers will weekly comQlete interviews with interviewable residents for 30 days to ensure Review of Resident #6's current Care Plan reflected the Resident was assessed for risk of severally impaired decision making abilities related to diagnosis of risk of increased confusion related to risk for decline in Activities of Daily Living (ADLs) related to . An observation on 03/29/17 at 10:20 a.m. revealed Resident #6 was well groomed and dressed. Resident #6 was returning to an activity after her session. Resident #6's wheel chair was clean and free of odors. Resident #6's finger nails and hands were clean with no visible debris. The resident smile at this investigator and joined the music activity. The Resident appeared calm and free of distress_ The resident was not interviewable and could not answer the investigator's questions at the time. . . Review of five (5) images screen captured by Citizen C from CNA D Snap Chat account reflected: Image 1 contained a conversation between CNA D and Citizen C. Citizen C - "This is soooo [sic] f""ked up not even FORM CMS-2567(02-99) Previous Versions Obsolete Event ID. OU1 Y11 Facility ID: 4970 ------ __ - -{ Formatted: Font: 9.5 pt there are no reQorts of lack of dignity grivacy abuse or mistreatment. A review of the facility',s grievances will be comgleted by the AdministratorLDesignee for 30 days to ensure that there are no regorts of lack of dignity, Qrivacy, abuse or mistreatment reQorted. Administrator or designee will meet with the Resident Council to re-educate residents on Resident Bill of Rights to include Privacy and Dignity. Results of these audits will be Qresented and reviewed at the QA Committee meeting for 90 days and POC will be UQdated to reflect changes as deemed necessary. - ------ Page 3 of 36 - -~tted: Font: 9.5 pt Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PAOV1DER/SUPPLIER/CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ 8. WING _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER PREFIX TAG C 03/31/2017 STREET ADDRESS. CITY. STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFIC:ENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 3 funny .... imagine if that was your parents smh (shaking my head) you could really lose your job over some dumb s.. t like this" CNA D - "Who gone [sic] make me loose [sic] my job surely not you! I'm not even going to sit here and getting [sic] into a debate about this at all. If you don't want to look at it then don't take me off snap if it's honestly that serious to you! You have no idea what happens in places like this. I wouldn't put my parents in anything like this place I'd take care of them." Citizen C - "You'll take care of your parents but you'll sit there and torture other people's?! That's sick al (as f.. k), and idk (I don't know) who the If (the f°k) you're talkin [sic] too lmfaooo (I am laughing my !°king ass off) I could EASILY have you fired, please don't test me lo! (laughing out loud) you're a child for this and I really lost a lotta [sic] respect for you be (because) of it, didn't think someone like you who KNOWS how it is there would do something like that, and don't EVER tell me I don't know what happens in places like that, that's what I grew up around. My Grammy Works" Image 2 contained CNA D's Snap Chat profile. The profile contained CNA D's name, birthday, work information, city of residence, and relationship status. Image 3 was a photo of Resident #6. Resident #6's fingers and hands were covered with a brown, dried substance that appeared to be fecal matter. The caption of the photos reflected 's·•tty lip ahhh" with four (4) tears of joy emoticons. Image 4 was a photo of Resident #6. Resident #6's nose appears to be tickled by a white object. The caption on the photo reflected four (4) tears of joy emoticons and one stuck-out tongue and a winking eye emoticons. AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 164 Image 5 was a photo of Resident #6. Resident #6 FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: OU1 Y11 Fac1l1ty ID: 4970 Page 4 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 0MB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ 8. WING _ _ _ _ _ _ _ _ __ 675956 C 03/31/2017 STREET ADDRESS. CITY. STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 4 was touching her face with her fingers with the brown matter on them, in what appeared to be an attempt at scratching the area of her nose that was being tickled in the second photo. The caption in this photo reflected, 'Crusty a•• s''t on her hands bro this hoe nasty al (as l"'k)", with an emoticon of a face with medical mask. AUSTIN, TX 78727 PROVIDER"S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 164 Review of the facility's Investigation Report, dated , reflected CNA D took pictures of Resident #6 in her room while on duty. The resident was assessed and observed for change in demeanor. The facility notified the resident's physician and family. On at 9:00 a.m., Citizen C contacted the facility and reported CNA D posted Snap Chat (social media) images online of a resident in the facility. CNA D was suspended pending the outcome of the investigation. Review of the facility's Employees Work Termination form, dated , reflected CNA D was involuntary terminated. The CNA was ineligible for rehire due to abuse. In an interview on 03/30/17 at 11:16 a.m. Citizen C stated she looked at CNA D's Snap Chat account and was immediately sick to her stomach. She stated she replayed the photos and screen captured them. She stated the first photo showed Resident #6 with a brown substance on her fingers that appeared to be feces, the second photo showed Resident #6's nose being tickled, and the third photo showed Resident #6 touching her face with her soiled hand. Citizen C stated she entered into a heated debate with CNA D, in which CNA D clearly saw no wrongdoing in his actions and gloated that he would not lose his job for his actions. Citizen C stated she was not aware of whom or how many people saw the FORM CMS-2567(02-99) Previous Versions Obsolete Event1D:0U1Y11 Facility ID 4970 Page 5 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MFDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER· B. WING _ _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER PREFIX TAG COMPLETED C 03/31/2017 STREET ADDRESS. CITY. STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID (X3) DATE SURVEY A. BUILDING _ _ _ _ _ _ _~ AUSTIN, TX 78727 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY ID PROVIDER'S PLAN OF CORRECTION (XS) PREFIX OR LSC IDENTIFYING INFORMATION) TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE F 164 Continued From page 5 F 164 photos. Citizen C stated she called the nursing home multiple times before she was able to reach management staff. Citizen C further stated she posted the images on (social media) because she didn't feel the facility was taking appropriate action and wanted to share her story of the incident that took place in the facility. In an interview on 03/30/17 at 11 :33 a.m. Resident #6's stated he was pretty disgusted with the images of his that were posted on social media. He stated he felt the facility failed to ensure his was respected and had personal privacy. He further stated the facility staff was not clear about what initially happened and mislead him until the media reported the incident. He stated he first learned of the details of the incident from the news media. In an interview on 03/30/17 at 2:05 a.m. CNA G stated she never expected anything like this to ever happen. She stated staff know not to have their phones on them during work hours and know not to take pictures of the residents. In an interview on 03/30/17 at 2:15 a.m. CNA H stated she never expected anything like the incident to happen at the facility. CNA H further stated that CNA D confirmed that he indeed took photos of Resident #6 touching her face, while her hand was covered with feces, and posted them on his Snap Chat account. In an interview on 03/30/17 at 2:20 a.m. Licensed Vocational Nurse (LVN) A and LVN B stated they were shocked by CNA D's actions. They stated after the incident, staff is no longer allowed to have their cell phones in the building. The LVNs stated they previously communicated with other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: au, v11 Facility 1D: 4970 Page 6 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION 0MB NO. 0938-0391 {X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 8. WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG {X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING l~FORMATION) F 164 Continued From page 6 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 164 staff including the DON while working in and out of residents' rooms. In an interview on 03/30/17 at 2:30 p.m. CNA K stated all staff was aware of the cell phone policy. She further stated all staff should have known not to take photos of residents and not to have phones in residents' rooms or on their hall ways. In an interview on 03/30/17 at 2:42 p.m. CNA L stated she was 'blown away" from the incident. She stated it was heartbreaking to see the images captured from CNA D's Snap Chat when seen in the media. She stated the situation was terrible and that they are trained to provide all residents with a good quality of life. In an interview on 03/30/17 at 3:00 p.m. LVN M stated when she learned of the incident she cried and thought, "How could this have happened?". She stated she would be 'upset and pissed" if it was her family. She stated the resident was vulnerable and that it was not right. LVN M further stated 'it hurt so bad" to see what happened. In an interview on 03/30/17 at 3:20 p.m. Registered Nurse (RN) N stated the incident was a terrible event that reflects on all the staff. She stated she would have felt inhuman, violated, embarrassed, and upset if this had occurred to her. In an interview on 03/30/17 at 4:10 p.m. Resident #1 and Resident #2 stated they were aware of the incident involving Resident #6 and CNA D. They stated although they felt safe in the facility, they could not believe something like that could happen. They stated it was terrible that it even took place and felt awful for the resident. ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: au, Y11 Facility ID: 4970 Page 7 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDlr.ARE & MEDICAID SERVICES '1' STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ B WING _ _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER PREFIX TAG C 03/31/2017 STREET ADDRESS. CITY. STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 7 AUSTIN, TX 78727 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (XS) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CATE F 164 In an interview on 03/29/17 at 10:10 a.m. the Director of Nursing (DON) stated they were made aware of the incident on He stated Citizen C notified the facility during the morning meeting and stated she could provide the screen captured photos of Resident #6. Once the facility received the photos of Resident #6 they were able to identify her. They immediately contacted CNA D and terminated him that day . The DON stated they assessed the resident and found no concerns. They notified the resident's family, physician, police, and the State Agency (DADS). The DON stated the photos revealed CNA D had intentionally tickled Resident #6's nose while she had a brown substance on her hand that could be fecal matter or chocolate pudding. The DON stated it gave them the opportunity to review policies on cell phone usage, abuse, and social media. (Although the DON provided in-servicing on HIPAA, the federal law that protects personal medical information and recognizes the rights to relevant medical information of family caregivers and others directly involved in providing or paying for care, he did not mention or provide in-servicing on personal privacy.) In an interview on 03/31/17 at 2:40 p.m. the Administrator stated on 03/28/17 the facility received a call from Citizen C stating she saw photos that were posted online of a resident in the facility. The citizen sent the screen captured photos to the facility management staff. The Administrator stated they were able to identify Resident #6. He stated they could not confirm 100% what was on the resident's hands, however, they terminated CNA D. He stated in the photos Resident #6 appeared to be instigated to =ORM CMS-2567(02-99) Previous Versions Obsolete Event ID· OU1 Y11 Facility ID: 4970 Page 8 of 36 Date Printed: 04/17/2017 5:52:0SPM FOAM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 675956 0MB NO 0938-0391 {X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 B WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL {X4) ID PREFIX TAG {X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 8 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFEAENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {XS) COMPLETION DATE F 164 touch her face with feces on her hand. The Administrator stated the facility immediately in-serviced on abuse, cell phones, and reporting abuse. (Although the Administrator provided in-servicing on HIPM, there was no evidence that training was provided on personal privacy.) The investigator asked the facility for a policy on Personal Privacy. The following was provided to the investigator. Review of the facility's Resident Bill of Rights, revised 04/2015, reflected: "1. The Resident has a right to a dignified existence self-determination and communication with and access to persons and services inside and outside this facility. He/she may exercise his/her rights as a citizen or Resident of the United States without interference, coercion, discrimination, or reprisal from the facility in exercising his/her rights ... 23. The Resident has the right to personal privacy and confidentiality of his/her personal and clinical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and Resident groups, but does not require the facility to provide a private room for each resident. 24. The facility ensures the Resident's right to privacy in the following areas: c. Personal care; 41. The Resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. RIGHTS OF THE ELDERLY FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1Y11 Facility JD: 4970 Page 9 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ B. WING _ _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4J ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 164 Continued From page 9 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 164 1. In addition to other rights an elderly individual has as a citizen, an elderly infidel has the rights provided by this section. 2. An elderly individual may not be physically or mentally abused or exploited. 5. An elderly individual should be treated with respect, consideration, and recognition of the individual's dignity and individuality. An elderly individual receives personal care and private treatment." Review of the facility provided Resident's Rights (FEDERAL LAW) policy, undated, reflected: "Each resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident including each of the following rights. 1. Each resident has a right to all care necessary for residents to have the highest possible level of health; 3. Each resident has a right to be free from abuse and exploitation; 4. Each resident has a right to be treated with courtesy, consideration and respect; 6. Each resident has a right to privacy, including privacy during visits and telephone calls; Each employee will be required and expected to uphold and promote the above Residents Rights, and all other Residents Rights established by law, in the course of preforming their job. Failure to do so may be grounds for disciplinary action including, but not limited to termination." Review of the facility provided resident list reflected 27 residents who resided on hall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID· OU1 Y11 Facility ID· 4970 Page 10 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVl<-:Es STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER. (X2) MULT\PLE CONSTRUCTION 8. WING _ _ _ _ _ _ _ _ __ 675956 PREFIX TAG COMPLETED C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID (X3) DATE SURVEY A. B U I L D I N G - - - - - - - - SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 10 F 223 483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SS=E SECLUSION AUSTIN, TX 78727 PROVIDER"S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 223 F 223 (XS) COMPLETION DATE Please refer to CMS form 2567 dated ~4/173G/1 03/31/17, F164 for plan of correction l I 483.12 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 symptoms. 483.12(a) The facility must(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 observation, interview, and record review, the facility failed to provide the resident the right to be free from neglect for one (1) of six (6) residents reviewed for abuse, neglect, and misappropriation of property. Certified Nursing Aide (CNA D) posted three (3) photos of Resident #6 on his Snap Chat account (social media) while providing care to the resident. The photos of Resident #6 revealed she had a brown-like substance that appeared to be feces on her hand, while her nose was intentionally tickled with an object, and the resident touched her face with her soiled hand. This deficient practice could place 27 residents who resided on hall at risk for abuse and diminished quality of life. Findings included: ORM CMS-2567(02-99) Previous Versions Obsolete Event 10· OU1 Y11 Facility ID: 4970 Page11 of36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 09~8-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER· (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 B. WING 675956 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 11 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 223 Review of Resident #6's Face Sheet, dated reflected the Resident was an year old female who was admitted the facility on Further review reflected Resident #6 had current diagnosis of Review of Resident #6's Quarterly Minimum Data Set (MOS), dated , reflected the resident's Brief Interview for Mental Status (BIMS) score was a 2 (0-7 range), reflecting severe impairment. Further record review reflected Resident #6 was frequently incontinent of bowel and bladder, and required one person physical and extensive assist for toileting. Review of Resident #6's current Care Plan reflected the Resident was assessed for risk of severally impaired decision making abilities related to diagnosis of risk of increased confusion related to risk for decline in Activities of Daily Living (ADLs) related to An observation on 03/29/17 at 10:20 a.m. revealed Resident #6 was well groomed and dressed. Resident #6 was returning to an activity after her session. Resident #6's wheel chair was clean and free of odors. Resident #6's finger nails and hands were clean with no visible debris. The resident smile at this investigator and joined the music activity. The Resident appeared calm and free of distress. The resident was not interviewable and could not answer the investigator's questions at the time. ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 12 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ 8. WING _ _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER TAG C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 12 AUSTIN, TX 78727 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (XS) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION DATE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F 223 Review of five (5) images screen captured by Citizen C from CNA D's Snap Chat account reflected: Image 1 contained a conversation between CNA D and Citizen C. Citizen C - "This is soooo [sic] f .. ked up not even funny .... imagine if that was your parents smh (shaking my head) you could really lose your job over some dumb shit like this" CNA D - "Who gone [sic] make me loose [sic] my job surely not you! I'm not even going to sit here and getting [sic] into a debate about this at all. If you don't want to look at it then don't take me off snap if it's honestly that serious to you! You have no idea what happens in places like this. I wouldnt put my parents in anything like this place I'd take care of them." Citizen C - 'You'll take care of your parents but you'll sit there and torture other people's?! That's sick al (as f.. k). and idk (I don't know) who the ti (the f .. k) you're talkin [sic] too lmfaooo (I am laughing my !**king a.. off) I could EASILY have you fired, please don't test me lol (laughing out loud) you're a child for this and I really lost a lotta [sic] respect for you be (because) of it, didn't think someone like you who KNOWS how it is there would do something like that, and don't EVER tell me I don't know what happens in places like that, that's what I grew up around. My GRAMMY Works" Image 2 contained CNA D's Snap Chat profile. The profile contained CNA D's name, birthday, work information, city of residence, and relationship status. Image 3 was a photo of Resident #6. Resident #6's fingers and hands were covered with a brown dried substance that appeared to be fecal matter. The caption of the phots reflected "sh ..ty lip ahhh" with four (4) tears of joy emoticons. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID OU1 Y11 Facility ID: 4970 Page 13 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED C 8.WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) 10 PREFIX TAG 03/31/2017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 13 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 223 Image 4 was a photo of Resident #6. Resident #6's nose appears to be tickled by a white object The caption on the photo reflected four (4) tears of joy emoticons and one (1) stuck-out tongue and winking eye emoticons. Image 5 was a photo of Resident #6. Resident #6 was touching her face with her fingers with the brown matter on them, in what appears to be an attempt at scratching the area of her nose that was being tickled in the second photo. The caption in this photo reflected, 'Crusty a•• s**t on her hands bro this hoe nasty al (as f**k)" with an emoticon of a face with a medical mask. Review of the facility's Investigation Report, dated reflected CNA D took pictures of Resident #6 in her room while on duty. The resident was assessed and observed for change in demeanor. The facility notified the resident's physician and at 9:00 a.m., Citizen C family. On contacted the facility and reported CNA D posted Snap Chat (social media) images online of a resident in the facility. CNA D was suspended pending the outcome of the investigation. Review of the facility's Employees Work Termination form, dated , reflected CNA D was involuntary terminated. The CNA was ineligible for rehire due to abuse. In an interview on 03/30/17 at 11 :16 a.m. Citizen C stated she looked at CNA D's Snap Chat account and was immediately sick to her stomach. She stated she replayed the photos and screen captured them. She stated the first photo showed Resident #6 with brown substance on her finger that appeared to be feces, the second photo showed resident #6's nose being tickled, and the third photo showed resident #6 touching ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID. 4970 Page 14 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF OEFIC1ENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION B. WING _ _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER TAG COMPLETED C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX (X3J DATE SURVEY A. BUILDING _ _ _ _ _ _ __ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT\FY!NG INFORMATION) F 223 Continued From page 14 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION ID PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 223 her face with her soiled hand. Citizen C stated she entered into a heated debate with CNA D, in which CNA D clearly saw no wrongdoing in his actions and gloated that he would not lose his job for his actions. Citizen C stated she was not aware of whom or how many people saw the photos. Citizen C stated she called the nursing home multiple times before she was able to reach management staff. Citizen B further stated she posted the images on (social media) because she didn't feel the facility was taking appropriate action and wanted to share her story of the incident that took place in the facility. In an interview on 03/30/17 at 11 :33 a.m. Resident #6's stated he was pretty disgusted with the images of his that were posted on social media. He stated he felt the facility failed to ensure his was respected and had personal privacy. He further stated the facility staff was not clear about what initially happened and mislead him until the media reported the incident. He stated he first learned of the details of the incident from the news media. In an interview on 03/30/17 at 2:05 a.m. CNA G stated she never expected anything like this to ever happen. She stated staff know not to have their phones on them during work hours and know not to take pictures of the residents. In an interview on 03/30/17 at 2:15 a.m. CNA H stated she never expected anything like the incident to happen at the facility. She stated the staff were in-serviced on several issues but were not in-serviced on dignity. CNA H further stated that CNA D confirmed that he indeed took photos of Resident #6 touching her face, while her hand was covered with feces, and posted them on his !=ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID. 4970 Page 15 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDEAISUPPLIEAICLIA IDENTIFICATION NUMBER· 0MB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 B WING 675956 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROV!OER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 15 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 223 Snap Chat account. In an interview on 03/30/17 at 2:20 a.m. Licensed Vocational Nurse (LVN) A and LVN B stated they were shocked by CNA D's actions. They stated after the incident, staff is no longer allowed to have their cell phones in the building. The LVNs stated they previously communicated with other staff including the DON while working in and out of residents' rooms. In an interview on 03/30/17 at 2:30 p.m. CNA K stated all staff was aware of the cell phone policy. She further stated all staff should have known not to take photos of residents and not to have phones in residents' rooms or their hall ways. In an interview on 03/30/17 at 2:42 p.m. CNA L stated she was 'blown away" from the incident. She stated it was heartbreaking to see the images captured from CNA D's Snap Chat when seen in the media. She stated the situation was terrible and that they are trained to provide all residents with a good quality of life. She stated she would have been devastated if this had happened to her, she would have felt it was a big dignity issue. In an interview on 03/30/17 at 3:00 p.m. LVN M stated when she learned of the incident she cried and thought, 'How could this have happened?". She stated she would be 'upset and pissed" if it was her family. She stated the resident was vulnerable and that it was not right. LVN M further stated "it hurt so bad" to see what happened. In an interview on 03/30/17 at 3:20 p.m. Registered Nurse (RN) N stated the incident was a terrible event that reflects on all the staff. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Fac11Jty ID: 4970 Page 16 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED 0MB NO. 0938-0191 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER, (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ C 03/31/2017 B.WING 675956 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 16 I 5301 W DUVAL RD AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 223 stated she would have felt inhuman, violated, embarrassed, and upset if this had occurred to her. In an interview on 03/30/17 at 4:10 p.m. Resident #1 and Resident #2 stated they were aware of the incident involving Resident #6 and CNA D. They stated although they felt safe in the facility, they could not believe something like that could happen. They stated it was terrible that it even took place and felt awful for the resident. In an interview on 03/29/17 at 2:48 p.m. the facility's Ombudsman stated she had received many complaints from resident concerning dignity. She stated the facility could benefit from in-services on dignity and has offered to provide help and education. She stated the facility should ensure all residents are treated with dignity and respect. In an interview on 03/29/17 at 10:10 a.m. the Director of Nursing (DON) stated they were made aware of the incident on . He stated Citizen C notified the facility during the morning meeting and stated she could provide the screen captured photos of Resident #6. Once the facility received the photos of Resident #6 they were able to identify her. They immediately contacted CNA D and terminated him that day . The DON stated they assessed the resident and found no concerns. They notified the resident's family, physician, police, and the State Agency (DADS). The DON stated the photos revealed CNA D had intentionally tickled Resident #6's nose while she had a brown substance on her hand that could be fecal matter or chocolate pudding. The DON stated it gave them the opportunity to review policies on cell phone ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 17 of 36 Date Printed: 04/17/2017 5:52:0SPM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTlON (Xt) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 675956 FORM APPROVED 0MB NO 0938 0391 (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ C 03/31/2017 B WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 223 Continued From page 17 usage, abuse, and social media_ AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTlON (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 223 In an interview on 03/31/17 at 2:40 p.m. the Administrator stated on 03/28/17 the facility received a call from Citizen C stating she saw photos that were posted online of a resident in the facility. The Citizen sent the screen captured photos to the facility management staff. The Administrator stated they were able to identify Resident #6. He stated they could not confirm 100% what was on the resident's hands; however,.they terminated CNA D. He stated in the photos Resident #6 appeared to be instigated to touch her face with feces on her hand. The Administrator stated the facility immediately in-serviced on abuse, cell phones, and reporting abuse. Review of the facility's policy titled Abuse Prevention Program, dated November 2016 reflected: Our residents have the right to be free from abuse/neglecVmisappropriation of resident's property/ corporal punishment and involuntary seclusion. 3. Comprehensive polices and procedures have been developed to aid our facility in preventing abuse/neglecVor mistreatment of our residents. Our abuse prevention program provides police and procedures that govern/as a minimum: b. Mandated staff training/orientation programs that include such topics as abuse prevention/identification and reporting of abuse/stress managemenVdealing with violent behavior or catastrophic reactions/ etc; Review of the facility provided resident list reflected 27 residents who resided on hall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID. OU1 Y11 Facility ID: 4970 Page 18 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEnlCAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULT\PLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 8. WING 675956 STREET ADDRESS. CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 483.12(b)(1)-(3), 483.95(c)(1)-(3) SS=E DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 226 Please refer to CMS form 2567 dated 03/31/17, F164 for plan of correction (XS) COMPLETION DATE I 04/1730/ '-T,-----..' 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at§ 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement their written policies and procedures to prohibit mistreatment, neglect, or ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Yt 1 Faci11ty ID: 4970 Page 19 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEl)ICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER OMA NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - C 03/31/2017 B. WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 Continued From page 19 abuse for one(1) of six (6) residents reviewed for abuse/neglect, who resident on hall when: AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 226 Certified Nursing Aide (CNA D) posted three (3) photos of Resident #6 on his Snap Chat account (social media) while providing care to the resident. The photos of Resident #6 revealed she had a brown-like substance that appeared to be feces on her hand, while her nose was intentionally tickled with an object, and the resident touched her face with her soiled hand. This deficient practice could place 27 residents who at risk for abuse and resided on hall diminished quality of life. Findings included: Review of the facility's policy titled Abuse Prevention Program, dated November 2016 reflected: Our residents have the right to be free from abuse/neglect/misappropriation of resident's property/ corporal punishment and involuntary seclusion. 3. Comprehensive polices and procedures have been developed to aid our facility in preventing abuse/neglect/or mistreatment of our residents. Our abuse prevention program provides police and procedures that govern/as a minimum: b. Mandated staff training/orientation programs that include such topics as abuse prevention/identification and reporting of abuse/stress management/dealing with violent behavior or catastrophic reactions/ etc; Further review of the policy reflected the facility did not update their policy in accordance with CMS guidelines to include policies and l:QRM CMS·2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facilrty ID: 4970 Page 20 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDlr.ARE & MED1r.AID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 675956 0MB NO. 09::18-0391 (X2) MULTIPLE CONSTRUCTION C 03/31/2017 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ID PREFIX TAG (XS) COMPLETION DATE DEFJCJENCY) F 226 Continued From page 20 procedures that prohibit staff from taking, keeping and/or distributing photographs and recording that demean or humiliate a resident(s) F 226 Review of Resident #6's Face Sheet, dated reflected the Resident was an year old female who was admitted the facility on . Further review reflected Resident #6 had current diagnosis of Review of Resident #6's Quarterly Minimum Data Set (MOS), dated , reflected the resident's Brief Interview for Mental Status (BIMS) score was a 2 (0-7 range). reflecting severe impairment. Further record review reflected Resident #6 was frequently incontinent of bowel and bladder, and required one person physical and extensive assist for toileting. Review of Resident #6's current Care Plan reflected the Resident was assessed for risk of severally impaired decision making abilities related to diagnosis of risk of increased confusion related to risk for decline in Activities of Daily Living {ADLs) related to An observation on 03/29/17 at 10:20 a.m. revealed Resident #6 was well groomed and dressed. Resident #6 was returning to an activity after her session. Resident #6's wheel chair was clean and free of odors. Resident #6's finger nails and hands were clean with no visible debris. The resident smile at this investigator and joined the music activity. The Resident appeared calm and free of distress. The resident was not FOAM CMS-2567(02-99) Previous Versions Obsolete Event 1D:0U1Y11 Facility ID: 4970 Page 21 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER· 0MB NO 0938 0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ _~ 8. WING _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 Continued From page 21 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION CATE F 226 interviewable and could not answer the investigator's questions at the time. Review of five (5) images screen captured by Citizen C from CNA D's Snap Chat account reflected: Image 1 contained a conversation between CNA D and Citizen C. Citizen C - 'This is soooo [sic] f .. ked up not even funny .... imagine if that was your parents smh (shaking my head) you could really lose your job over some dumb shit like this' CNA D - "Who gone [sic] make me loose [sic] my job surely not you! I'm not even going to sit here and getting [sic] into a debate about this at all. If you don't want to look at it then don't take me off snap if it's honestly that serious to you! You have no idea what happens in places like this. I wouldn't put my parents in anything like this place I'd take care of them." Citizen C - "You'll take care of your parents but you'll sit there and torture other people's?! That's sick al (as f"k), and idk (I don't know) who the ti (the f"k) you're talkin [sic] too lmfaooo (I am laughing my !"king a•• off) I could EASILY have you fired, please don't test me lol (laughing out loud) you're a child for this and I really lost a lotta [sic] respect for you be (because) of it, didn't think someone like you who KNOWS how it is there would do something like that, and don~ EVER tell me I don't know what happens in places like that, that's what I grew up around. My GRAMMY Works" Image 2 contained CNA D's Snap Chat profile. The profile contained CNA D's name, birthday, work information, city of residence, and relationship status. Image 3 was a photo of Resident #6. Resident #6's fingers and hands were covered with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 22 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO 0938 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED C B WING 675956 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPUEA WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG SUMMARY STATEMENT CF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 Continued From page 22 I 5301 W DUVAL RD AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 226 brown dried substance that appeared to be fecal matter. The caption of the phots reflected "sh''ty lip ahhh" with four (4) tears of joy emoticons. Image 4 was a photo of Resident #6. Resident #6's nose appears to be tickled by a white object. The caption on the photo reflected four (4) tears of joy emoticons and one (1) stuck-out tongue and winking eye emoticons. Image 5 was a photo of Resident #6. Resident #6 was touching her face with her fingers with the brown matter on them, in what appears to be an attempt at scratching the area of her nose that was being tickled in the second photo. The caption in this photo reflected, "Crusty a" s"t on her hands bro this hoe nasty af {as f"k)" with an emoticon of a face with a medical mask. Review of the facility's Investigation Report, dated , reflected CNA D took pictures of Resident #6 in her room while on duty. The resident was assessed and observed for change in demeanor. The facility notified the resident's physician and family. On at 9:00 a.m., Citizen C contacted the facility and reported CNA D posted Snap Chat {social media) images online of a resident in the facility. CNA D was suspended pending the outcome of the investigation. Review of the facility's Employees Work Termination form, dated , reflected CNA D was involuntary terminated. The CNA was ineligible for rehire due to abuse. In an interview on 03/30/17 at 11 :16 a.m. Citizen C stated she looked at CNA D's Snap Chat account and was immediately sick to her stomach. She stated she replayed the photos and screen captured them. She stated the first photo showed Resident #6 with brown substance on her FORM CMS-2567(02-99) Previous Versions Obsolete Event1D:0U1Y11 Facility ID 4970 Page 23 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER· (X2) MULTIPLE CONSTRUCTION C 03/31/2017 B. WING 675956 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE (XS) COMPLETION DATE DEFICIENCY) F 226 Continued From page 23 F 226 finger that appeared to be feces, the second photo showed resident #6's nose being tickled, and the third photo showed resident #6 touching her face with her soiled hand. Citizen C stated she entered into a heated debate with CNA D, in which CNA D clearly saw no wrongdoing in his actions and gloated that he would not lose his job for his actions. Citizen C stated she was not aware of whom or how many people saw the photos. Citizen C stated she called the nursing home multiple times before she was able to reach management staff. Citizen B further stated she posted the images on (social media) because she didn't feel the facility was taking appropriate action and wanted to share her story of the incident that took place in the facility. In an interview on 03/30/17 at 11 :33 a.m. Resident #6's stated he was pretty disgusted with the images of his that were posted on social media. He stated he felt the facility failed to ensure his was respected and had personal privacy. He further stated the facility staff was not clear about what initially happened and mislead him until the media reported the incident. He stated he first learned of the details of the incident from the news media. In an interview on 03/30/17 at 2:05 a.m. CNA G stated she never expected anything like this to ever happen. She stated staff know not to have their phones on them during work hours and know not to take pictures of the residents. In an interview on 03/30/17 at 2:15 a.m. CNA H stated she never expected anything like the incident to happen at the facility. She stated the staff were in-serviced on several issues but were not in-serviced on dignity. CNA H further stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1Y11 Facility ID: 4970 Page 24 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ C 03/31/2017 B. WING 675956 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY DA LSC IDENTIFYING INFORMATION) F 226 Continued From page 24 that CNA D confirmed that he indeed took photos of Resident #6 touching her face, while her hand was covered with feces, and posted them on his Snap Chat account. AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F226 In an interview on 03/30/17 at 2:20 a.m. Licensed Vocational Nurse (LVN) A and LVN B stated they were shocked by CNA D's actions. They stated after the incident, staff is no longer allowed to have their cell phones in the building. The LVNs stated they previously communicated with other staff including the DON while working in and out of residents' rooms. In an interview on 03/30/17 at 2:30 p.m. CNA K stated she was shocked by the incident. She stated all staff was aware of the cell phone policy. She further stated all staff should have known not to take photos of residents and not to have phones in residents' rooms or their hall ways. In an interview on 03/30/17 at 2:42 p.m. CNA L stated she was 'blown away" from the incident. She stated it was heartbreaking to see the images captured from CNA D's Snap Chat when seen in the media. She stated the situation was terrible and that they are trained to provide all residents with a good quality of life_ She stated she would have been devastated if this had happened to her, she would have felt it was a big dignity issue. In an interview on 03/30/17 at 3:00 p.m. LVN M stated when she learned of the incident she cried and thought, "How could this have happened?". She stated she would be "upset and pissed" if it was her family_ She stated the resident was vulnerable and that it was not right. LVN M further stated "it hurt so bad" to see what happened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID· 4970 Page 25 of 36 Date Printed: 04/17/2017 5:52:0SPM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CllA IDENTIFICATION NUMBER. FORM APPROVED 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ 8. WING _ _ _ _ _ _ _ _ __ 675956 C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3J DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 Continued From page 25 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 226 In an interview on 03/30/17 at 3:20 p.m. Registered Nurse (RN) N stated the incident was a terrible event that reflects on all the staff. She stated she would have felt inhuman, violated, embarrassed, and upset if this had occurred to her. In an interview on 03/30/17 at 4:10 p.m. Resident #1 and Resident #2 stated they were aware of the incident involving Resident #6 and CNA D. They stated although they felt safe in the facility, they could not believe something like that could happen. They stated it was terrible that it even took place and felt awful for the resident. In an interview on 03/29/17 at 2:48 p.m. the facility's Ombudsman stated she had received many complaints from resident concerning dignity. She stated the facility could benefit from in-services on dignity and has offered to provide help and education. She stated the facility should ensure all residents are treated with dignity and respect. In an interview on 03/29/17 at 10:10 a.m. the Director of Nursing (DON) stated they were made aware of the incident on He stated Citizen C notified the facility during the morning meeting and stated she could provide the screen captured photos of Resident #6. Once the facility received the photos of Resident #6 they were able to identify her. They immediately contacted CNA D and terminated him that day . The DON stated they assessed the resident and found no concerns. They notified the resident's family, physician, police, and the State Agency (DADS). The DON stated the photos revealed CNA D had intentionally tickled Resident #6's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID· OU1 Y11 Facility ID: 4970 Page 26 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO 0938 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIER/CLIA IDENTIFICATICN NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ C 03/31/2017 8. WING 675956 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFIClENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 226 Continued From page 26 nose while she had a brown substance on her hand that could be fecal matter or chocolate pudding. The DON stated it gave them the opportunity to review policies on cell phone usage, abuse, and social media. AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 226 In an interview on 03/31/17 at 2:40 p.m. the Administrator stated on 03/28/17 the facility received a call from Citizen C stating she saw photos that were posted online of a resident in the facility. The Citizen sent the screen captured photos to the facility management staff. The Administrator stated they were able to identify Resident #6. He stated they could not confirm 100% what was on the resident's hands; however, they terminated CNA D. He stated in the photos Resident #6 appeared to be instigated to touch her face with feces on her hand. The Administrator stated the facility immediately in-serviced on abuse, cell phones, and reporting abuse. Review of the facility provided resident list reflected 27 residents who resided on hall Please refer to CMS form 2567 dated F 241 483.10(a)(1) DIGNITY AND RESPECT OF SS=E INDIVIDUALITY F 241 03/31/17. F164 for plan of correction ~1 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to promote care for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 27 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEnlCAID SERVlr.Es STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER. (X2) MULTIPLE CONSTRUCTION 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 STREET ADDRESS. CITY. STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER PREFIX TAG COMPLETED 8. WING 675956 (X4) ID (X3) DATE SURVEY A. BUILDING _ _ _ _ _ _ __ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION ID PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE (XS) COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 27 residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for one (1) of six (6) residents who resident on hall when: F 241 Certified Nursing Aide (CNA D) posted three (3) photos of Resident #6 on his Snap Chat account (social media) while providing care to the resident. The photos of Resident #6 revealed she had a brown-like substance that appeared to be feces on her hand, while her nose was intentionally tickled with an object, and the resident touched her face with her soiled hand. These failures could result in a decline in self-esteem for the 27 residents who resided on hall Findings included: Review of Resident #6's Face Sheet, dated , reflected the Resident was an year old female who was admitted the facility on Further review reflected Resident #6 had current diagnosis of Review of Resident #6's Quarterly Minimum Data Set (MDS), dated reflected the resident's Brief Interview for Mental Status (BIMS) score was a 2 (0-7 range), reflecting severe impairment. Further record review reflected Resident #6 was frequently incontinent of bowel and bladder, and required one person physical and ex1ensive assist for toileting. ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facihty ID: 4970 Page 28 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 0MB NO 0938 0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ B. WING _ _ _ _ _ _ _ __ 675956 NAME OF PROVIDER OR SUPPLIER F 241 C 03/31/2017 STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 28 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {XS) COMPLETION DATE F 241 Review of Resident #6's current Care Plan reflected the Resident was assessed for risk of severally impaired decision making abilities related to diagnosis of risk of increased confusion related to risk for decline in Activities of Daily Living (ADLs} related to An observation on 03/29/17 at 10:20 a_m. revealed Resident #6 was well groomed and dressed. Resident #6 was returning to an activity after her session. Resident #6's wheel chair was clean and free of odors. Resident #6's finger nails and hands were clean with no visible debris. The resident smile at this investigator and joined the music activity. The Resident appeared calm and free of distress. The resident was not interviewable and could not answer the investigator's questions at the time. Review of five (5) images screen captured by Citizen C from CNA D's Snap Chat account reflected: Image 1 contained a conversation between CNA D and Citizen C. Citizen C • "This is soooo [sic] f.. ked up not even funny .... imagine if that was your parents smh (shaking my head} you could really lose your job over some dumb shit like this" CNA D - "Who gone [sic] make me loose [sic] my job surely not you! I'm not even going to sit here and getting [sic] into a debate about this at all. If you don't want to look at it then don't take me off snap if it's honestly that serious to you! You have no idea what happens in places like this. I wouldn't put my parents in anything like this place I'd take care of them." Citizen C - "You'll take care of your parents but you'll sit there and torture other people's?! That's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility 10: 4970 Page 29 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PAOVIDER/SUPPL1ER/CL1A IDENTIFICATION NUMBER. 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED C B. WING 675956 NAME OF PROVIDER OR SUPPLIER WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL (X4) ID PREFIX TAG F 241 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 sick al (as , .. k), and idk (I don't know) who the tf (the , .. k) you're talkin [sic] too lmfaooo (I am laughing my !'*king a.. off) I could EASILY have you fired, please don't test me lol (laughing out loud) you're a child for this and I really lost a lotta [sic] respect for you be (because) of it, didn't think someone like you who KNOWS how it is there would do something like that, and don't EVER tell me I don't know what happens in places like that, that's what I grew up around. My GRAMMY Works" Image 2 contained CNA D's Snap Chat profile. The profile contained CNA D's name, birthday, work information, city of residence, and relationship status. Image 3 was a photo of Resident #6. Resident #6's fingers and hands were covered with a brown dried substance that appeared to be fecal matter. The caption of the phots reflected "sh ..ty lip ahhh" with four (4) tears of joy emoticons. Image 4 was a photo of Resident #6. Resident #6's nose appears to be tickled by a white object. The caption on the photo reflected four (4) tears of joy emoticons and one (1) stuck-out tongue and winking eye emoticons. Image 5 was a photo of Resident #6. Resident #6 was touching her face with her fingers with the brown matter on them, in what appears to be an attempt at scratching the area of her nose that was being tickled in the second photo. The caption in this photo reflected, "Crusty a .. s"t on her hands bro this hoe nasty al (as f.. k)' with an emoticon of a face with a medical mask. 03/31/2017 I STREET ADDRESS, CITY, STATE. ZIP CODE 5301 W DUVAL RD AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F241 Review of the facility's Investigation Report, dated reflected CNA D took pictures of Resident #6 in her room while on duty. The resident was assessed and observed for change in demeanor. The facility notified the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID·OU1Y11 Facility 10 4970 Page 30 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL PREFIX TAG F 241 C 03/31/2017 8. WING 675956 (X4J ID (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 30 physician and family. On at 9:00 a.m., Citizen C contacted the facility and reported CNA D posted Snap Chat (social media) images online of a resident in the facility. CNA D was suspended pending the outcome of the investigation. AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 241 Review of the facility's Employees Work Termination form, dated reflected CNA D was involuntary terminated. The CNA was ineligible for rehire due to abuse. In an interview on 03/30/17 at 11 :16 a.m. Citizen C stated she looked at CNA D's Snap Chat account and was immediately sick to her stomach. She stated she replayed the photos and screen captured them. She stated the first photo showed Resident #6 with brown substance on her finger that appeared to be feces, the second photo showed resident #6's nose being tickled, and the third photo showed resident #6 touching her face with her soiled hand. Citizen C stated she entered into a heated debate with CNA D, in which CNA D clearly saw no wrongdoing in his actions and gloated that he would not lose his job for his actions. Citizen C stated she was not aware of whom or how many people saw the photos. Citizen C stated she called the nursing home multiple times before she was able to reach management staff. Citizen B further stated she posted the images on (social media) because she didn't feel the facility was taking appropriate action and wanted to share her story of the incident that took place in the facility. In an interview on 03/30/17 at 11 :33 a.m. Resident #6's stated he was pretty disgusted with the images of his that were posted on social media. He stated he felt the facility failed to ensure his was respected and had l=QRM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 31 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID ~ERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1J PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER· (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ STREET ADDRESS. CITY. STATE. ZIP CODE NAME OF PROVIDER DA SUPPLIER 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 B. WING 675956 (X4J ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 31 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 241 personal privacy. He further stated the facility staff was not clear about what initially happened and mislead him until the media reported the incident. He stated he first learned of the details of the incident from the news media. In an interview on 03/30/17 at 2:05 a.m. CNA G stated she never expected anything like this to ever happen. She stated staff know not to have their phones on them during work hours and know not to take pictures of the residents. She stated they were in-serviced on several topics; however, were not in-serviced on dignity recently. In an interview on 03/30/17 at 2:15 a.m. CNA H stated she never expected anything like the incident to happen at the facility. She stated the staff were in-serviced on several issues but were not in-serviced on dignity. CNA H further stated that CNA D confirmed that he indeed took photos of Resident #6 touching her face, while her hand was covered with feces, and posted them on his Snap Chat account. In an interview on 03/30/17 at 2:20 a.m. Licensed Vocational Nurse (LVN) A and LVN B stated they never expected anything so awful to take place in the facility. They stated they were shocked by CNA D's actions. They stated after the incident, staff is no longer allowed to have their cell phones in the building. The LVNs stated they previously communicated with other staff including the DON while working in and out of residents' rooms. In an interview on 03/30/17 at 2:30 p.m. CNA K stated all staff was aware of the cell phone policy. She further stated all staff should have known not to take photos of residents and not to have phones in residents' rooms or their hall ways. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID. OU1 Y11 Facility ID: 4970 Page 32 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVlf;ES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1 I PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 0MB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 B.WING 675956 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 32 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F241 In an interview on 03/30/17 at 2:42 p.m. CNA L stated she was "blown away" from the incident. She stated it was heartbreaking to see the images captured from CNA D's Snap Chat when seen in the media. She stated the situation was terrible and that they are trained to provide all residents with a good quality of life. She stated she would have been devastated if this had happened to her, she would have felt it was a big dignity issue. In an interview on 03/30/17 at 3:00 p.m. LVN M stated when she learned of the incident she cried and thought, "How could this have happened?". She stated she would be 'upset and pissed" if it was her family. She stated the resident was vulnerable and that it was not right. LVN M further stated "it hurt so bad" to see what happened. In an interview on 03/30/17 at 3:20 p.m. Registered Nurse (RN) N stated the incident was a terrible event that reflects on all the staff. She stated she would have felt inhuman, violated, embarrassed, and upset if this had occurred to her. In an interview on 03/30/17 at 4:10 p.m. Resident #1 and Resident #2 stated they were aware of the incident involving Resident #6 and CNA D. They stated although they felt safe in the facility, they could not believe something like that could happen. They stated it was terrible that it even took place and felt awful for the resident. In an interview on 03/29/17 at 2:48 p.m. the facility's Ombudsman stated she had received many complaints from resident concerning dignity. She stated the facility could benefit from ~ORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 33 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MFDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER1SUPPL1ER/CL1A IDENTIFICATION NUMBER 0MB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 8. WING 675956 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 33 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE OEFIClENCY) ID PREFIX TAG (XS) COMPLETION DATE F 241 in-services on dignity and has offered to provide help and education. She stated the facility should ensure all residents are treated with dignity and respect. In an interview on 03/29/17 at 10:10 a.m. the Director of Nursing (DON) stated they were made aware of the incident on He stated Citizen C notified the facility during the morning meeting and stated she could provide the screen captured photos of Resident #6. Once the facility received the photos of Resident #6 they were able to identify her. They immediately contacted CNA D and terminated The DON stated they him that day assessed the resident and found no concerns. They notified the resident's family, physician, police, and the State Agency (DADS). The DON stated the photos revealed CNA D had intentionally tickled Resident #6's nose while she had a brown substance on her hand that could be fecal matter or chocolate pudding. The DON stated it gave them the opportunity to review policies on cell phone usage, abuse, and social media. (The DON did not mention or provide in-servicing on dignity.) In an interview on 03/31/17 at 2:40 p.m. the Administrator stated on 03/28/17 the facility received a call from Citizen C stating she saw photos that were posted online of a resident in the facility. The Citizen sent the screen captured photos to the facility management staff. The Administrator stated they were able to identify Resident #6. He stated they could not confirm 100% what was on the resident's hands; however, they terminated CNA D. He stated in the photos Resident #6 appeared to be instigated to touch her face with feces on her hand. The Administrator stated the facility immediately FORM CMS-2567(02-99) Previous Versions Obsolete EventlD:OU1Y11 Facility ID: 4970 Page 34 of 36 Date Printed: 04/17/2017 5:52:05PM FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 675956 0MB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE 5301 W DUVAL WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Continued From page 34 RD AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFlC!ENCY) ID PREFIX TAG (XS) COMPLETION DATE F241 in-serviced on abuse, cell phones, and reporting abuse. (The Administrator did not mention or provide in-servicing on dignity.) The investigator asked the facility for a policy on Dignity. The following was provided to the investigator. Review of the facility's Resident Bill of Rights, revised 04/2015 reflected: "1. The Resident has a right to a dignified existence self-determination and communication with and access to persons and services inside an outside this facility. He/she may exercise his/her rights as a citizen or Resident of the United States without interference, coercion, discrimination, or reprisal from the facility in exercising his/her rights ... 23. The Resident has the right to personal privacy and confidentiality of his/her personal and clinical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and Resident groups, but does not requires the facility to provide a private room for each resident. 24. The facility ensures the Resident's right to privacy in the following areas: c. Personal care; 41. The Resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. RIGHTS OF THE ELDERLY 1 . In addition to other rights an elderly individual has as a citizen, an elderly infidel has the rights provide by this section. FORM CMS-2567(02-99) Previous Versmns Obsolete Event ID: OU1 Y11 Facility ID: 4970 Page 35 of 36 Date Printed: 04/17/2017 5:52:0SPM FORM APPROVED 0MB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDlr.ARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 675956 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ STREET ADDRESS. CITY, STATE. ZIP CODE 5301 W DUVAL RD WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL F 241 C 03/31/2017 B WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATIE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 35 AUSTIN, TX 78727 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIHE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 241 2. An elderly individual man not be physically or mentally abused or exploited. 5. An elderly individual should be treated with respect, consideration, and recognition of the individual's dignity and individuality. An elderly individual receives personal care and private treatment." Review of the facility provided Resident's Rights (FEDERAL LAW) policy, undated, reflected: "Each resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident including each of the following rights. 1. Each resident has a right to all care necessary for residents to have the highest possible level of health; 3. Each resident has a right to be free from abuse and exploitation; 4. Each resident has a right to be treated with courtesy, consideration and respect; 6. Each resident has a right to privacy, including privacy during visit and telephone calls; Each employee will be required and expected to uphold and promote the above Residents Rights, and all other Residents Rights established by law, in the course of preforming their job. Failure to do so may be grounds for disciplinary action including, but not limited to termination.' Review of the facility provided resident list reflected 27 residents who resided on hall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OU1 Vt 1 Facility ID: 4970 Page 36 of 36 ~J.liator}'S,,,JiC'.1!$ STA1flB4!EMJ" OF ID.E!Flit:11!3N!OES A'tl!DIP.!A'll1IOF~l!l!rl! f(Or,rm l!ll1+.Ill5 Jn" STATEMENT OF LICENSING VIOLATIONS AND PLAN OF CORRECTION T X . ~ ! d f ~rn;i ;amjjlllJ,sa:,litt,vSm>irna ~1f.i ffim"!Of.lRIS\P.Pl.:~ l!C!BNJi!fll:CA:ncrt, lll!L'!M3ER: .llJ.:Jly2lt.!5 PRlmED: ~71l7lllil17 «-J;2,)~ll:IPJ£00T~l!lru! A.IBL'IUJD!Ti!G: _ _ _ _ _ _ __ 5'.~'5-4'>~ ~)IDA7ESUR:.'.E'!!' la Vll!Ti!G _ _ _ _ _ _ _ __ ~ C 0313112017 smEET JIDD'P"'.-SS.• crnr. S1T"A11'E.. ZIP' allIJlE Wlffl>SOR NURSING AND REHABIUTATION ~ STA'Taef!' 5301 W DUVAL RD AUSTIN, TX 7B7Z1 a= IDffilCIE'tl,'C:IES ll'l!ID>':!Cffl'S ll'Ul.'N O F ~ ~~l/EA'CTIOO SOOUJ.DEE ~~TOTHE~TE ~ r n E F ~ i!lffUS1f SE PRECiEDED BY fl.1il. lrc:Gl.1JATOR'f OR ts:: ll!llEKT~ ll!i!Fl'.liRT.'l,\TIOtJ) ~ t.l 000 Initial Comments NOOO A complaint and incident investigation (#852553, #852721, and #852787) was conducted on 03/29/17 to 03/31/17 at Windsor Nursing and Rehabilitation Center of Duval. The facility census was 193. Please refer to CMS form 2567 dated mrr, TAC §19.407 Privacy and Confidentiality SS=E·· N t.1887 03/31/17, F164 for plan of correction in reference to N887, N982, l'J983. and The resident has the right to personal privacy and confidentiality of his personal and dinical records. (See also §19.1910(e} of this title (relating to I Clinical Records) and §19.403(e) of this title (relating to Notice of Rights and Services). r-,31006. · This Requirement is not met as evidenced by: Refer to CMS 2567 dated 03/31/17, F-164 for evidence of this violation. N 9 · TAC §19.601(b) Abuse SS=E (b) Abuse. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. N982 r- s r-,1 c-2 C> >- c::C :::E: Cl u.J > C) 0::: Cl- This Requirement is not met as evidenced by: e..