Every finding on record at Breathitt Health & Rehabilitation

Based on interview, record review, facility policy review and review of the Resident Assessment Instrument (RAI) Manual guidelines, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two of 41 sampled residents (R) R1 and R5).Findings included: A facility policy titled Certifying Accuracy of the Resident Assessment, dated 01/05/2025, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further indicated 3. The information captured on the assessment reflects the status of the resident during the observation ( look-back) period for that assessment. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated, section K0520: Nutritional Approaches and provided coding instructions for K0520A, parenteral/IV [intravenous] feeding. The RAI manual further indicated, Coding Tips for K0520A and included, Parenteral/IV feeding - The following fluids may be included when there is supporting documentation that reflects the needs for additional fluid intake specifically addressing a nutrition or hydration need. The list included, IV fluids can be coded in K5020A if needed to prevent dehydration if the additional fluid intake is specifically needed for nutrition and/or hydration. Prevention of dehydration should be clinically indicated and supporting documentation should be provided in the medical record. The following items are NOT to be coded in K0520A: - IV Medications - Code these when appropriate in O0110H, IV Medications. - IV fluids used to reconstitute and/or dilute medications for IV administration. - IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay. - IV fluids administered solely as flushes. 1. An admission Record revealed the facility admitted Resident 1 on 01/07/2020. According to the admission record, the resident had a medical history that included diagnoses of Alzheimer's disease, congestive heart failure, protein-calorie malnutrition, and neuropathy. A quarterly MDS, with an Assessment Reference Date (ARD) of 12/31/2025, indicated, under section K0520, that Resident #1 had received Parenteral/IV feeding within the past seven days while a resident of the facility. Resident 1's Order Recap [Recapitulation] Report contained an order for ceftriaxone sodium solution reconstituted 1 gram intravenously every 24 hours for infection for five days with a start date of 12/28/2025. The physician orders did not include an order for IV fluids or IV nutrition. Resident 1's Medication Administration Record (MAR) for the timeframe from 12/01/2025 through 12/31/2025 revealed no documented evidence of the administration of IV fluids or IV nutrition. Resident 1's Care Plan Report revealed no documented evidence of IV fluids or IV nutrition. During an interview on 03/18/2026 at 11:31 AM, the MDS Coordinator (MDS 1) stated Resident 1 received an IV antibiotic during the MDS observation period. MDS 1 stated when a resident received IV antibiotics, she coded it in section O and in section K0520A of the MDS. MDS 1 stated she did not know why the IV hydration and nutrition was coded for Resident 1. 2. An admission Record revealed the facility admitted Resident 5 on 08/07/2023. According to the admission Record, the resident had a medical history that included diagnoses of protein-calorie malnutrition, dysphagia, and dementia. An annual MDS, with an Assessment Reference Date (ARD) of 12/31/2025, indicated, under section K0520, that Resident 5 had received Parenteral/IV feeding, within the past seven days while a resident of the facility. Resident 5's Order Recap [Recapitulation] Report contained an order for meropenem intravenous solution reconstituted 1 gram intravenously every 8 hours for osteomyelitis until 02/02/2026 with a start date of 12/28/2025. The physician orders also contained an order for normal saline flush intravenous solution 10 milliliters for peripherally inserted central catheter (PICC) maintenance. The physician orders did not include an order for IV fluids or IV nutrition. Resident 5's Medication Administration Record (MAR) for the timeframe from 12/01/2025 through 12/31/2025 revealed no documented evidence of the administration of IV fluids or IV nutrition. Resident 5's Care Plan Report revealed no documented evidence of IV fluids or IV nutrition. During an interview on 03/18/2026 at 11:31 AM, MDS 1 stated Resident 5 received IV antibiotics during the MDS observation period. MDS 1 stated when a resident received IV antibiotics, she coded it in section O and section K0520A of the MDS. MDS 1 stated that was how she had been told to do it. MDS 1 reviewed the RAI manual and stated that she had misread the instructions, and the IV antibiotics should not have been coded in section K of the MDS. During an interview on 03/18/2026 at 11:50 AM, the Restorative and MDS Nurse (MDS 2) stated that a resident should be coded for IV nutrition in section K of the MDS if they received IV fluids. MDS 2 stated IV antibiotics would be coded under section O, not section K. MDS 2 reviewed the electronic health record for Resident 1 and confirmed that Resident 1 had not received IV fluids during the MDS observation period. MDS 2 stated that the IV nutrition and hydration was coded in error. MDS 2 reviewed R5's electronic health record and confirmed that R5 had not received IV fluids during the MDS observation period, and it was coded in error. During an interview on 03/18/2026 at 12:34 PM, the Director of Nursing (DON) stated she expected the MDS assessments to be completed according to the RAI manual guidelines. The DON stated she did not think that IV antibiotics would be coded as IV nutrition and hydration. During an interview on 03/18/2026 at 12:37 PM, the MDS consultant stated IV antibiotics should be coded under section O, not under section K. During an interview on 03/18/2026 at 12:41 PM, the Administrator stated her expectation was that the MDS should be coded correctly following the policy and the RAI manual.

Based on interview, record review and review of the facility's policy, the facility failed to ensure each resident remained free from abuse for 1 of 19 sampled residents, (Resident (R)2). R2 alleged Certified Nursing Assistant (CNA)2 was rough while providing care on 12/24/2024. R2 further alleged CNA2 told her, if you report me, I will beat your ass. R2 was crying and told RN1 that she was afraid of CNA2. (Refer to F609, and 610 ) The findings include: Review of the facility's policy, titled Abuse Prevention Program, undated, revealed the facility would prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Further review revealed the program would be implemented when an employee or agent became aware of abuse or neglect of a resident, or if an allegation of suspected abuse or neglect of a resident was reported. Review of R2's electronic medical record (EMR), under the Face Sheet revealed the facility admitted the resident on 08/01/2024 with diagnoses that included Multiple Sclerosis, Anxiety and Depression. Review of R2's Comprehensive Care Plan revised 08/01/2024, located in the Electronic Medical Record (EMR), under the Care Plan tab, revealed no focus area noted for R2 related to any behaviors. Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/2024, located in the EMR under the MDS tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Further review of the MDS revealed R2 was dependent for transfers, utilized a wheelchair and was assessed as no ambulation. No behaviors were coded on the MDS. During an interview on 02/02/2025 at 1:58 PM, with R2, she stated on 12/24/2024, CNA2 was rough while providing care. Continued interview revealed CNA2 continued to provide rough care and R2 told the CNA that if she continued to be rough during care, she would report her. R2 stated CNA2 responded, if you report me, I will beat your ass. R2 stated CNA2's treatment of her on 12/24/2024, hurt her feelings. R2 stated, CNA1, who was assigned to the resident, was in her room assisting with pulling her up in bed during the incident. R2 stated she reported the incident to CNA6. During an interview on 02/05/2025 at 9:54 AM, with CNA6, she stated upon entering R2's room on 12/24/2024, the resident was crying. When CNA6 questioned R2, she stated CNA2 told her she would smack the fire out of her if she (R2) reported the rough care that she had provided. CNA6 stated this was her recollection of what R2 reported to her. CNA6 stated she did not document this and was not asked to write a statement. CNA6 stated she immediately reported this to Registered Nurse (RN)1. During an interview on 02/04/2025 at 3:06 PM, with CNA2, she stated she had not been in R2's room on 12/24/2024. Further, CNA2 stated she had not been in R2's room in more than a month prior to the allegation being made on 12/24/2024. CNA2 stated she could not recall why she had been instructed not to go into R2's room the month prior to the allegation, but thought the Director of Nursing (DON) may have been the person who instructed her not to go into R2's room. In further interview, CNA2 stated that on 12/24/2024, she was instructed by RN1 to go to the breakroom and was then informed of R2 alleging she (CNA2) had threatened to hit her. CNA2 stated the Administrator then spoke with her on the phone on 12/24/2024 and instructed her not to go back into R2's room or the hallway where R2 resided, but to continue working on another unit providing Resident care. During an interview on 02/05/2025 at 11:45 AM, with RN1, she stated on 12/24/2024 just after supper, around 5:00 PM, CNA6 reported an allegation related to CNA2. RN1 stated R2 reported to CNA6, that CNA2 told R2 if she did not quiet down, she would slap the shit out of her. RN1 stated she went to R2's room, and noticed R2 with the bed covers pulled under her chin. She stated R2 appeared agitated. RN1 stated R2 told her she was afraid of CNA2. In continued interview, RN1 stated she had CNA1 and CNA2 to remain in the break room while she contacted the Administrator by phone. RN1 stated the Administrator then had her to take the phone to R2 and the Administrator spoke with R2 for approximately 20 minutes. The RN stated CNA1 and CNA2 remained in the breakroom during this time. RN1 stated the Administrator spoke with CNA1 and CNA2 via phone after speaking with R2. RN1 stated she informed the Administrator of the allegation of verbal abuse as well as the allegation of rough care provided to R2 by CNA2. Additional interview on 02/05/2025 at 11:45 AM, with RN1, revealed after the Administrator spoke with R2, CNA1, and CNA2 via phone, the Administrator told RN1 to have CNA2 to go to the front hall and continue working. RN1 stated the Administrator informed her she was going to close the investigation because she did not suspect any abuse. RN1 stated the Administrator instructed her to ensure CNA2 did not go back down the hallway where R2 resided. During an interview on 02/04/2025 at 3:28 PM, with the DON, she stated she did not recall why CNA2 was instructed prior to the 12/24/2024 allegation, not to be in R2's room. However, it must have been some type of conflict. The DON stated CNA2 was not assigned to R2 on 12/24/2024, but may have been assisting another CNA on that day. During an interview on 02/03/2025 at 2:14 PM with R2's sister, she stated that on 12/24/2024 between 7:30-8:00 PM, upon entering the facility she was informed by RN1 that R2 had alleged rough care by CNA2 and reported CNA2 had told her she would beat the shit out of her if she reported her. The sister stated RN1 had also informed her that R2 had been crying and maybe she could help calm her down. Upon entering the room, R2 appeared to have been crying and stated her feelings were hurt. R2 then repeated to the sister the same allegation as RN1 had informed her of. During an interview, on 02/04/2025 at 11:27 AM, with the Administrator, she stated she was responsible for abuse investigations at the facility. She stated she was contacted on 12/24/2024 by RN1 and informed of the allegation made by R2. The Administrator stated after learning of the incident, she had a 20 minute conversation with R2 and during the call R2 could not explain what she meant by the CNA being rough. The Administrator stated after speaking with R2, CNA1, and CNA2, she did not identify an allegation of abuse. However, she stated she was not made aware R2 had alleged CNA2 stated she would beat the shit out of her. The Administrator stated she was only informed R2 had stated CNA2 was rough while providing care. However, during interview on 02/05/2025 at 11:45 AM, RN1 stated she informed the Administrator of the verbal statement and the rough care allegation made by R2. The Administrator stated she did not interview other residents regarding CNA2 as she stated she had never had any complaints regarding CNA2. During an interview on 02/06/2025 at 5:08 PM, with the Medical Director, he stated he was made aware of an allegation made by R2 on 12/24/2024. The Medical Director stated he was informed by the Administrator that R2 alleged an aide had been abusive or rough while providing care. The MD stated he was informed by the Administrator that the allegation had been worked out and R2 did not like CNA2 and there had not been any type of abuse. In further interview, the Medical Director stated he was informed R2 was unhappy with CNA2, therefore the facility had moved CNA2, so she would not have further contact with R2. 52131

Based on interview, record review, and review of the facility's policy, the facility failed to report an allegation of abuse to the State Agencies and local law enforcement for 1 of 19 sampled residents, (Resident (R)2). The facility failed to report an allegation of abuse after R2, while crying, alleged on 12/24/2024, to CNA6 that Certified Nursing Assistant (CNA}2 was rough while providing care and told R2, if you report me, I will beat your ass. R2 then informed RN1 that she was afraid of CNA2. Registered Nurse1 (RN1) Refer to F600 and F610. The findings include: Review of the facility's policy, titled Abuse Reporting, undated, revealed the Administrator or person in charge, would notify immediately, the state licensing and certification agency, the resident's representative, the attending physician, and law enforcement officials when the facility received an allegation of abuse. Review of R2's electronic medical record under the Face Sheet revealed the facility admitted the resident on 08/01/2024 with diagnoses which included Multiple Sclerosis, Anxiety and Depression. Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/2024, located under the MDS tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Additional review of the MDS, revealed the facility assessed the resident as having no behaviors, as totally dependent on staff for transfers, and as ambulation not occurring. During an interview on 02/02/2025 at 1:58 PM, with R2, she stated on 12/24/2024, CNA2 was rough while providing care. R2 stated CNA2 continued to provide rough care and she told CNA2, if she continued to be rough during care, she would report her. R2 stated CNA2 then responded, if you report me, I will beat your ass. R2 stated she reported this to CNA6; however, she was unaware of the time of the occurrence or the time she reported it to CNA6. Further, R2 stated CNA1 was in the room assisting to pull R2 up in bed during this incident. R2 stated RN1 brought the phone in her room and R2 spoke with the Administrator. R2 stated she informed the Administrator of CNA2's statement that she would beat her ass if R2 reported her for being so rough while providing care. During an interview on 02/05/2025 at 9:54 AM, with CNA6, she stated upon entering R2's room just after supper, the resident was crying. CNA6 stated R2 alleged CNA2 told her, she would smack the fire out of her if R2 reported her being rough with her care. CNA6 stated this was what she remembered related to the conversation. However, she was not asked to write a statement related to the allegation. CNA6 stated she immediately reported the allegation to Registered Nurse (RN)1. During an interview on 02/05/2025 at 10:39 AM, with CNA1, she stated she could not remember if CNA2 was in R2's room on 12/24/2024. During an interview on 02/04/2025 at 3:06 PM, with CNA2, she denied being in R2's room on 12/24/2024. CNA2 stated on 12/24/2024 she was instructed by RN1 to go to the breakroom and was then informed that R2 had accused her (CNA2) of saying she was going to hit her. During an interview, on 02/05/2025 at 11:45 AM, with RN1, she stated on 12/24/2024 around 5:00 PM, CNA6 reported an allegation. RN1 stated per her recollection, R2 told CNA6, that CNA2 told her if she did not quiet down, she would slap the shit out of her. RN1 stated she then went immediately to R2's room and spoke with her. The RN stated during her conversation with R2, the resident told her she was afraid of CNA2. RN1 stated she did not document this allegation, but had CNA1 and CNA2 stay in the break room while she contacted the Administrator. RN1 stated the Administrator spoke with R2 on the phone while CNA1 and CNA2 remained in the breakroom, and then the Administrator spoke with CNA1 and CNA2 by phone. During an interview on 02/03/2025 at 2:14 PM with R2's sister, she stated that on 12/24/2024 between 7:30-8:00 PM, upon entering the facility she was informed by RN1 that R2 had alleged rough care by CNA2 and reported CNA2 had told her she would beat the shit out of her if she reported her. The sister stated RN1 had also informed her that R2 had been crying and maybe she could help calm her down. Upon entering the room, R2 appeared to have been crying and stated her feelings were hurt. R2 then repeated to the sister the same allegation as RN1 had informed her of. During interview with RN1, on 02/05/2025 at 11:45 AM, she stated after the Administrator spoke with R2, CNA1, and CNA2 by phone, which was just after 5:00 PM, the Administrator told her to have CNA2 to go to the front hall and continue working as she did not suspect any abuse. In further interview with RN1, she stated the Administrator instructed her to not allow CNA2 to go back down the hallway where R2 resided. RN 1 stated she informed the Administrator of the allegation of verbal abuse as well as the allegation of rough care provided to R2 by CNA2. During an interview on 02/04/2025 at 11:27 AM, with the Administrator, she stated on 12/24/2024 around 5:00 PM, RN1 informed her of an allegation of CNA2 providing rough care made by R2. The Administrator stated she then had a 20 minute conversation with R2 via phone, and during this call R2 was unable to explain what she meant by the CNA being rough. The Administrator stated she then spoke with CNA1, and CNA2. She stated after the phone interviews with R2, CNA1 and CNA2, she did not feel this was an allegation of abuse, but only a concern and therefore she did not report the allegation to State Agencies or local law enforcement. However, she stated she was not made aware R2 had alleged that CNA2 told her she would beat the shit out of her. The Administrator stated she was only informed R2 had stated CNA2 was rough while providing care. During an interview on 02/06/2025 at 5:08 PM, with the Medical Director, he stated he was made aware of an allegation made by R2 on 12/24/2024 by the Administrator. The Medical Director stated he was told R2 alleged an aide had been abusive or rough while providing care. He stated he was further informed the allegation had been worked out and although R2 did not like CNA2, there had not been any type of abuse. In further interview, the Medical Director stated he would expect the facility to report any allegations of abuse to the appropriate state entities. 52131

Based on interview, record review and review of the facility's policy, the facility failed to conduct a thorough investigation in response to an alleged violation of abuse, for 1 of 19 sampled residents (Resident (R)2). R2 reported Certified Nursing Assistant (CNA)2 was rough while providing care on 12/24/2024. R2 reported CNA2 told her, if you report me, I will beat your ass. However, the facility failed to conduct a thorough investigation related to the allegation of abuse. CNA2 was allowed to continue working on 12/24/2024 unsupervised, allowing for the potential of further abuse. (Refer to F600, and F609) The findings include: Review of the facility's policy, titled Abuse Prevention Program, undated, revealed all incidents would be documented, whether abuse occurred, was alleged or suspected. Furthermore, any incident or allegation involving abuse or mistreatment would result in an abuse investigation. Review of the facility's policy titled Abuse Reporting, revealed the Administrator was the Abuse Coordinator. Review of R2's electronic medical record (EMR), under the Face Sheet revealed the facility admitted the resident on 08/01/2024 with diagnoses that included Multiple Sclerosis, Anxiety and Depression. Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/2024, located in the EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Additional review of the MDS, revealed the facility assessed the resident as having no behaviors, as totally dependent on staff for transfers, and as ambulation not occurring. In an interview on 02/02/2024 at 1:58 PM, with R2, she stated on 12/24/2024, CNA2 was rough while providing care. R2 further stated CNA2 continued to provide care, and R2 told CNA2 that if she continued to be rough during care, she would report her. R2 stated CNA2 replied, if you report me, I will beat your ass. R2 stated she reported this to CNA6. Additionally, R2 stated CNA1 was in the room at the time of the incident assisting with pulling her up in the bed. In an interview on 02/05/2025 at 9:54 AM, with CNA6, she stated upon entering R2's room on 12/24/2024, the resident was crying. CNA6 stated when R2 was questioned, she stated CNA2 had said she would smack the fire out of her if she (R2) reported the rough care CNA2 had provided. CNA6 stated this was her recollection of what was stated to her by R2, as she did not document the allegation nor was she asked to write a statement. CNA6 stated she immediately reported the allegation to Registered Nurse (RN)1. In an interview on 02/05/2025 at 10:39 AM, CNA1 stated she could not remember if CNA2 was in R2's room on 12/24/2024. CNA1 stated the Administrator interviewed her over the phone related to the allegation, but she was not asked to write a statement. In an interview on 02/04/2025 at 3:06 PM, CNA2 stated she had not been in R2's room on 12/24/2024. CNA2 stated she had not been in R2's room in more than a month prior to the allegation being made on 12/24/2024. The CNA stated she could not remember why she had been told not to go into R2's room the month prior to the allegation, but the Director of Nursing (DON) may have been the person who instructed her not to go into R2's room. CNA2 stated on 12/24/2024, she was instructed by RN1 to go to the breakroom and was then informed of R2's allegation that she (CNA2) had threatened to hit the resident. In continued interview with CNA2, she stated she had spoken on the phone with the Administrator on the evening of 12/24/2024. She stated she was instructed to continue working her shift, but to stay on the front hall away from R2's room. CNA2 stated she was not asked to write a statement and continued to work as scheduled. In an interview with RN1, on 02/05/2025 at 11:45 AM, she stated on 12/24/2024 around 5:00 PM, CNA6 reported to her an allegation made by R2. RN1 stated CNA6 reported she was informed by R2, that CNA2 told R2 if she didn't quiet down, CNA2 would slap the shit out of her. RN1 stated this was her recollection of what was stated to her by R2, as she did not document this nor was she asked to write a statement. RN1 stated she went to R2's room and noted the resident had her blanket pulled up to her chin and stated she was afraid of CNA2. In interview with RN1, on 02/05/2025 at 11:45 AM, she stated she instructed CNA1 and CNA2 to remain in the break room while she contacted the Administrator by phone. RN 1 stated she informed the Administrator of the allegation of verbal abuse and the allegation of rough care provided to R2 by CNA2. RN1 stated the Administrator had her to take the phone to R2 and the Administrator spoke with R2 on the phone for approximately 20 minutes while CNA1 and CNA2 remained in the breakroom. RN1 stated the Administrator then spoke with CNA1 and CNA2 via phone. She stated that after the Administrator spoke with her, CNA1, and CNA2 she informed her that she was going to end the investigation because she did not suspect any abuse. She stated the Administrator instructed her to have CNA2 to go to the front hall and continue working and to ensure CNA2 did not go back down the hall where the resident resided. RN1 stated the Administrator did not instruct her to complete any documentation, investigation, or monitoring regarding the allegation other than to ensure CNA2 did not go back down the hall where R1 resided. During the interview with RN1she stated she did not document any monitoring of CNA2 to ensure CNA2 did not got to R2's hallway. In an interview on 02/04/2025 at 11:40 AM, with the Social Services Director (SSD), she stated on 12/24/2024 the Administrator notified her by phone that R2 had made a complaint stating that CNA2 had provided rough care. The SSD stated this was discussed in the morning standup meeting on Monday morning following the incident. The SSD stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and she monitored R2 for three (3) days with no issues noted. However, the SSD stated she could not locate any documentation for the follow-up or monitoring of R2. In an interview with the ADON, on 02/04/2025 at 3:35 PM, she stated she was informed by the Administrator of the allegation by R2, and was told CNA2 had provided rough care. The ADON stated she assisted with monitoring of R2 for three (3) days following the allegation and R2 did not mention anything regarding the incident. However, the ADON was unable to submit documented evidence of the three (3) day monitoring. During the interview, the ADON stated if abuse was alleged or suspected, the alleged perpetrator should be removed from the building and an investigation should be completed. However, she stated CNA2 was not sent home after the allegation because R2 only stated CNA2 provided rough care. The ADON stated she did not complete any interviews related to the allegation as she was not instructed to do so by the Administrator, who was responsible for the investigation. In an interview on 02/04/2025 with the DON, she stated she assisted with monitoring of R2 for two to three (2-3) days after the 12/24/2024 allegation was made. The DON stated the resident did not appear in any distress nor did she have any complaints. However, the DON was unable to submit documented evidence of the monitoring. During further interview, the DON stated she did not recall why CNA2 was instructed prior to the 12/242024 allegation, not to be in R2's room, but it was over some type of conflict. The DON stated she did not conduct any interviews related to the allegation, as the Administrator did not instruct her to do so. Review of a handwritten document, dated 12/24/2024, signed by the Administrator, revealed the Administrator was contacted around 7:00 PM by RN1. Per the document, RN1 reported R2 had stated CNA2 was rough with her while providing care. However, the the Administrator was unable to submit further investigation related to the allegation. In an interview with the Administrator, on 02/04/2025 at 11:27 AM, she stated she was contacted on 12/24/2024 by RN1 and informed of the allegation made by R2. She stated she had a 20-minute conversation with R2 and throughout the call, R2 could not explain what she meant by the CNA being rough. The Administrator stated after speaking with R2, CNA1, and CNA2 she thought this was only a concern as she was only informed R2 had stated CNA2 was rough while providing care. She stated she did not think there needed to be an abuse investigation nor did she think CNA2 needed to be removed from resident care. However, during continued interview with the Administrator, she stated she was not made aware that CNA2 had told R2 she would beat the shit out of her. In an interview, on 02/06/2025 at 5:08 PM, with the Medical Director, he verified the Administrator made him aware of an allegation made by R2 on 12/24/2024. He stated R2 alleged CNA2 had been abusive or rough while providing care. He stated the DON and the ADON had conducted interviews and concluded there was no physical or verbal abuse. The Medical Director stated he would expect the facility to conduct a thorough investigation and CNA2 be removed from the facility while an investigation was completed. 52131

Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Dietary staff failed to check six (6) of 12 food temperatures on the steam table during the dinner meal on [DATE]. Additionally, dietary staff failed to discard eight (8) expired food items. The findings include: 1. Review of the facility's policy titled, Food & Beverage Temperature Control, undated, revealed food and beverage temperatures were checked and recorded prior to meal service. Further review revealed all staff would ensure residents received safe food served at acceptable temperatures. Observation on [DATE] at 5:07 PM, revealed Cook1 failed to check the food temperatures for the mashed potatoes, beef goulash, pureed green beans, pureed rice, pureed bread, and pureed beef goulash on the steam table prior to serving the dinner meal. During an interview with Cook1, on [DATE] at 5:07 PM, she stated she only checked the temperature of the foods on the main steam table, not the pureed foods. 2. Review of the facility's policy titled,Food Safety, undated, revealed food or beverage items that had exceeded the manufacturer's expiration date would be discarded. Observation on [DATE] at 2:02 PM, revealed seven (7) expired food items in the walk-in refrigerator and one (1) expired food item in the pantry. The expired food items in the walk-in refrigerator included Dill Pickle Chips with an expiration date of [DATE]; Less Sodium Soy Sauce with an expiration date of [DATE]; another Less Sodium Soy Sauce with no lid with an expiration date of ,d+[DATE]; Wishbone Zesty [NAME] Italian Dressing with an expiration date of [DATE]; Worcestershire Sauce with an expiration date of [DATE]; and two (2) bottles of Lemon Juice with expiration dates of [DATE] and [DATE]. Observation of the pantry revealed one (1) pack of flour tortillas in saran wrap that was hardened with a date of [DATE] and [DATE] handwritten on the saran wrap. During interview with the Dietary Manager, on [DATE] at 1:07 PM, she stated all food served to residents should have a temperature check prior to serving. The Dietary Manager further stated if the food was not the correct temperature it could cause the residents to become sick. Continued interview revealed it was all dietary staff's responsibility to check the pantry, freezers, and refrigerators for expired food. During an interview with the Administrator, on [DATE] at 2:32 PM, she stated checking the temperature of all foods prior to serving should be part of the dietary staff's routine. She further stated it was important to check food temperatures at the steam table prior to serving because if the food temperatures were not the correct temperatures, this could lead to foodborne illnesses for the residents. The Administrator stated there should not be any expired food in the kitchen as expired food could possibly cause residents to become sick.

Based on interview, record review, and review of the facility's policy, the Map 14 form, the facility failed to protect the resident's rights to privacy in communications, including the right to receive mail unopened for 1 of 13 residents who attended the Group Interview (Resident (R) 40). R40 received an opened letter addressed to him from the Kentucky Public Pensions Authority. The findings include: Review of the facility's policy, titled Resident Rights, revised 11/01/2024, revealed its purpose was to protect and promote the rights of each resident. Per policy, each resident has a right to personal privacy, including the right to privacy in oral, written, and electronic communications and the right to receive mail unopened. Review of the facility's policy, titled Breathitt Health and Rehab Clinical Standard and Guidance Postal Services/ Mail Guideline, revealed its purpose was to ensure the facility protected the resident's rights to communication with individuals within and externally to the facility. Per policy, each resident has the right to send and promptly receive unopened mail, letters, and packages delivered by the USPS (United States Postal Service) and other authorized delivery services/carriers. Only if directed by the resident or the resident's Power of Attorney would any mail or package be opened by staff. During a Group Interview Meeting, conducted by the State Survey Agency Representative, on 02/04/2025 at 2:49 PM, R40 complained he had received a letter addressed to him that had been opened by facility staff. Review of R40's Electronic Medical Record (EMR), revealed a Quarterly Minimum Data Set (MDS) Assessment, dated 09/16/2024. Per the MDS, the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of R40's EMR, revealed no documented evidence R40 was informed his mail would be opened nor was this documented in the resident's Care Plan. Review of the Map 14-Commonwealth of Kentucky Cabinet for Health and Family Services Department for Medicaid Services Authorized Representative, revised 10/2021, revealed R40 signed this consent form, allowing the Business Manager to apply, report changes, recertify, and receive a copy of notices for his Medicaid eligibility. During interview with R40, on 02/05/2025 at 11:40 AM, the resident stated the facility's Business Manager opened and read a letter from the Kentucky Public Pensions Authority which was addressed to him (R40). R40 stated the Business Manager stopped him outside her office and told him about the letter's contents. He further stated he had not given the Business Manager permission to open this letter. In continued interview, R40 stated he had been excited to receive this letter, and it upset him that he did not get to experience reading the content himself. R40 stated, staff reading his letter made him feel like he didn't exist. Review of R40's letter from the Kentucky Public Pensions Authority, revealed the letter was addressed to R40. During an interview with the Business Manager, on 02/05/2025 at 11:36 AM, she stated she had opened R40's letter which was addressed to R40 from the Kentucky Public Pensions Authority. She stated she thought R40 granted her permission to open his mail from the Kentucky Public Pensions Authority when he signed the Map 14 form. During an interview with the Administrator, on 02/06/2025 at 2:30 PM, she stated she expected all residents to receive unopened mail to protect their right to privacy in communication. The Administrator stated the Business Manager should only open the resident's mail if the letter was addressed to the business office or if the resident had given permission to open the mail.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of 19 sampled residents (Resident (R)7, R28, and R50). 1. Observation on 02/02/2025 at 6:00 PM, revealed Certified Nursing Assistant (CNA)7 failed to don (put on) Personal Protective Equipment (PPE) prior to providing care for R7 who was on Enhanced Barrier Precautions (EBP). Additionally, CNA7 failed to wash or sanitize hands upon exiting R7's room after providing care. 2. Observations on 02/02/2025; 02/03/2025; 02/05/2025; and 02/06/2025, revealed R28's urinal was not labeled with the resident's name, nor was it dated or covered. R28's urinal was either lying on the floor or hanging from the rail in the bathroom. 3. Observation on 02/03/2025 at 9:47 AM, revealed R50's bathroom had two (2) unlabeled, undated, uncovered urinals on the back of the commode, and an uncovered bedpan. The findings include: Review of the facility's policy, titled Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. EBP would be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. Further review revealed high contact care activities included assisting with providing hands on care. 1. Review of R7's Face Sheet in the Electronic Medical Record (EMR), under the clinical information tab, revealed the facility admitted the resident on 09/12/2024 with diagnoses including lack of coordination and failure to thrive. Review of R7's Physician's Orders dated 10/10/2024, revealed orders for Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) related to a history of Methicillin-resistant Staphylococcus aureus (MRSA) found in the wound. EBP included wearing the appropriate Personal Protective Equipment (PPE) which included a disposable gown and gloves. Observation on 02/02/2025 at 6:00 PM, revealed an orange dot at R7's door which meant the resident was on EBP. Additionally, there was a sign on the door that stated Enhanced Barrier Precautions. Further observation revealed there was a cart at the door which contained boxes of gloves and disposable gowns. During observation of dinner meal pass on 02/02/2025 at 6:00 PM, Certified Nursing Assistant (CNA)7 failed to don Personal Protective Equipment (PPE) prior to entering R7's room with a meal tray. CNA7 proceeded to lower the head of the bed and assist the resident up higher in the bed by holding the resident under her shoulder while the resident bent her knees and pushed herself up. After assisting R7 up higher in the bed, CNA7 failed to wash or sanitize her hands upon exiting the room. CNA7 then proceeded to the beverage cart outside of R7's room in the hallway to obtain water and orange juice for R7. CNA7 was observed going back into R7's room without donning PPE and proceeded to assist the resident with her dinner tray. During an interview with CNA7, on 02/05/2025 at 9:22 AM, she stated if PPE was not donned appropriately for Enhanced Barrier Precautions (EBP), it placed the resident, other residents and staff at risk for spread of infection. CNA 7 stated all residents on EBP should not be touched by staff unless staff was wearing gloves and a disposable gown. CNA7 stated, she always tried to don appropriate PPE prior to entering R7's room and she knew she should wash or sanitize her hands upon exiting the room. She stated, I must have been in a hurry. I would never put any of my residents at risk for getting an infection or bacteria. During interview with Registered Nurse (RN) 1, on 02/02/2025 at 6:18 PM, she stated all staff had been educated on infection control policies and an orange dot on the resident's room number indicated the resident was on EBP. RN 1 stated all staff should be aware they were to don the appropriate PPE before providing any type of care for residents on EBP. RN1 stated she monitored as she was going down the halls and if staff was identified not wearing appropriate PPE, she would immediately educate them. The RN stated the Director of Nursing (DON) completed daily rounds for infection control measures as well. During an interview, on 02/05/2025 at 1:46 PM, the Director of Nursing/Infection Preventionist (DON/IP), stated she expected nursing staff to follow the facility's policies regarding PPE and EBP. The DON/IP stated if she ever saw any staff not following proper infection control procedures, she would immediately provide them education on what they did wrong and the corrective actions needed. The DON/IP stated following infection control policies and procedures for a resident on EBP was important in order to prevent other residents or staff from being exposed. Further, she stated it was important to use good hand hygiene after providing care, and upon exiting a resident's room. The DON/IP further stated she had been the DON and IP for almost five (5) years. She stated she tried to make daily rounds and educate staff regarding infection control procedures as needed. 2. Review of the facility's policy, titled Bedpan/Urinal, Offering/Removing, undated, revealed per the general guidelines, bedpans and/or urinals were required to be labeled with the resident's name and would be stored in a clean and dignified manner. Continued review revealed bedpans or urinals would not be left in the bathroom or on the floor. During the initial tour of the facility, on 02/02/2025 at 2:40 PM, there was a urinal which was not labeled with R28's name, was not dated, and was uncovered. The urinal was sitting on the floor next to R28's bed, which was out of reach for the resident. Interview with R28 on 02/02/2025 at 2:40 PM, revealed staff assisted him with using the urinal so he would not have placed the urinal on the floor. Further interview revealed the resident required staff to check his brief as he was sometimes incontinent. Review of R28's Quarterly Minimum Data Set (MDS), dated [DATE], located in the electronic medical record, revealed the facility assessed the resident as having a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. Continued review revealed the facility assessed R28 as being frequently incontinent of bladder. Observations on 02/02/2025 at 5:16 PM; 02/03/2025 at 10:15 AM; 02/05/2025 at 2:43 PM; and 02/06/2025 at 9:23 AM, revealed R28's urinal was unlabeled with the resident's name, undated, and uncovered on the floor or hanging from the rail in the bathroom. During interview with CNA5, on 02/02/2025 at 2:58 PM, she stated R28 was totally dependent on staff for toileting and was not able to place the urinal on the floor. CNA5 stated she was not sure who placed the urinal on the floor, but it had to be a staff member. CNA5 stated she had been trained on bedpans and urinals and both were to be labeled with the resident's name, dated and stored in a bag to prevent the spread of bacteria. The CNA stated urinals were not to be placed on the floor per the facility's policy. During interview with Registered Nurse (RN)1, on 02/02/2025 at 3:14 PM, she stated urinals were to be labeled with the resident's name, dated and placed in a bag and kept in the bathroom unless the resident had a preference of keeping it on a bedside table for easier reach. However, RN1 stated R28 was totally dependent for urinary needs and would not be able to use the urinal independently. She stated it was an infection control issue if the urinals weren't labeled with the resident's name, dated and bagged as it could spread bacteria to not only that resident but to another resident. 3. During observation on 02/03/2025 at 9:47 AM, R50's bathroom had two (2) urinals which were unlabeled with the resident's name, undated, and uncovered sitting on the back of the commode. Additionally, there was an uncovered bedpan on the back of the commode. During an interview on 02/05/2025 at 1:46 PM with the Director of Nursing/Infection Preventionist (DON/IP), she stated the urinals should be labeled with resident's name, dated, bagged, and stored per facility policy. She stated the urinals should be stored per the resident's preference. The DON/IP stated she made daily rounds. However, she did not go into residents' bathrooms during those rounds. She stated it was an infection control issue if urinals and bed pans were not labeled, dated and bagged as it could potentially cause the spread of bacteria which could lead to urinary tract infections. She stated all nursing staff was responsible for making sure the policy was followed. During an interview, on 02/06/2025 at 2:32 PM, with the Administrator, she stated general hand washing was number one, and donning PPE as indicated was expected of all staff. She stated she left it to her clinical management to make rounds to ensure there were no infection control concerns. She stated she expected all staff to follow the facility's infection control policies. 52131

Based on observation, interview, record review, review of the facility's investigation, and facility policy review, it was determined that the facility failed to ensure one (1) of five (5) sampled residents (Resident #1) was protected from verbal/mental abuse. On 05/30/2020, Resident #1 reported activating his/her call light to request staff assistance with toileting. However, due to a long wait, the resident was incontinent of urine. When State Registered Nurse Aide (SRNA) #2 arrived to assist the resident (almost an hour after the call light was activated), the SRNA called the resident an idiot and placed an incontinence brief on the resident against the resident's wishes. The resident told the SRNA that she was going to cry and SRNA #2 responded that if the resident cried, she would leave the resident's room. Interview with Resident #1 on 06/10/2020 revealed the resident was still upset and tearful when asked about the incident stating the incident made me feel really bad and hurt my feelings. The findings include: Review of the facility's policy titled, Abuse Prohibition-Abuse, Neglect, and Misappropriation of Property, undated, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury .with resulting physical harm or pain or mental anguish .It includes verbal, sexual, physical & mental abuse . Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. The policy defined verbal abuse as any use of oral, written or gestured language that included disparaging and/or derogatory terms to residents or their families, within hearing distance, or to describe residents, regardless of their age or ability to comprehend or disability. Review of the medical record for Resident #1 revealed the facility admitted the resident on 03/13/2017, with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. The MDS also revealed Resident #1 had been assessed to require the extensive assistance of two (2) staff members for bed mobility and toileting. The MDS revealed the resident was on a toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident #1's restorative toileting care plan reviewed on 04/07/2020, and the resident's SRNA care plan dated May 2020, revealed two (2) staff members were required to assist the resident with toileting. Further review of the care plan revealed the resident was on a toileting plan and no interventions had been developed regarding the resident wearing an incontinence brief. Observation and interview conducted with Resident #1 on 06/10/2020 at 9:40 AM, revealed on 05/30/2020 it had taken staff over one (1) hour to answer his/her call light. The resident stated, I had to wait too long and went (urinated) on myself. Resident #1 stated when SRNA #2 came into his/her room, she stated, Why did you do that, you idiot?. Resident #1 told SRNA #2 it was because it had taken so long for someone to answer the call light. The resident with tears in his/her eyes stated, It made me feel really bad and hurt my feelings. The resident stated SRNA #2 changed the resident's clothes and sheets and proceeded to put an incontinence brief on the resident. Resident #1 stated he/she told the SRNA that he/she did not want a brief, but the SRNA put it on anyway and stated, You have to keep from having another accident. The resident stated he/she then cried because it hurt his/her feelings, and SRNA #2 threatened to leave the resident's room if he/she cried. The resident stated he/she waited until LPN #2 came on duty to report the incident because the resident felt more comfortable talking to her. Review of a Resident Abuse Investigation Report Form dated 05/30/2020, revealed the facility conducted an investigation of Resident #1's allegations. Review of the facility's report revealed the resident's initial allegation to the facility was the same recollection of events that the resident reported to the surveyor during his/her interview on 06/10/2020. The report stated that Resident #1 reported to Licensed Practical Nurse (LPN) #2 on 05/30/2020 that he/she had activated his/her call light because the resident needed to use the restroom. The resident stated he/she waited for approximately one (1) hour before staff arrived to assist him/her with toileting and was incontinent of urine while waiting for assistance. The investigation revealed when SRNA #2 entered the resident's room to assist the resident, the SRNA stated, Why did you do that, you idiot?. Resident #1 was about to cry and the SRNA stated, If you do that (cry), I will leave the room. Further review revealed SRNA #2 placed an incontinence brief on the resident, even though the resident told the SRNA that he/she did not want to wear a brief. According to the facility's investigation, the resident's feelings were hurt. Interview with Licensed Practical Nurse (LPN) #2 on 06/11/2020 at 12:15 PM, revealed she was asked to go to Resident #1's room at approximately 10:00 PM on 05/30/2020, when Resident #1 reported the allegation. The LPN stated the resident was very upset when he/she reported the allegations regarding the SRNA's treatment of [REDACTED]. A review of a progress note written by Advanced Practice Registered Nurse (APRN) #1 dated 06/02/2020 revealed on 05/30/2020, Resident #1 reported to the APRN negative verbal speech from SRNA during an episode of urinary incontinence. (Resident #1) stated (he/she) was okay now but that it did hurt (his/her) feelings. Review of SRNA #2's statement dated 06/02/2020, revealed she entered Resident #1's room and provided incontinence care for Resident #1 alone (even though the resident required the assistance of two staff members) after 2:00 PM on 05/30/2020. The SRNA stated that she did not place an incontinence brief on the resident and did not call the resident an idiot, but did tell the resident that she would leave the room if the resident cried, because she would cry too. According to SRNA #2's statement, she had asked other staff to let her know if any of the residents' call lights were ringing because she was in another resident's room and could not hear the call light. Interview conducted with SRNA #2 on 06/10/2020 at 10:10 AM, revealed after she left the faciity on [DATE], facility staff notified her that she was suspended due to an allegation involving Resident #1. She stated that prior to the phone call, she was not aware of any problems with Resident #1. According to SRNA #2, on 05/30/2020 at approximately 10:00 AM, Resident #1 was about to cry because he/she had an incontinence episode. The SRNA admitted that she told the resident if he/she cried, she would leave the room. However, the SRNA stated she made the statement because she was emotional that day and would have cried if she had seen the resident crying. SRNA #2 stated she probably should not have told Resident #1 that she would leave the room. The SRNA also admitted that she placed an incontinence brief under the resident to prevent future accidents. SRNA #2 stated she provided incontinence care for the resident again at approximately 2:00 PM on 05/30/2020; however, the SRNA denied putting an incontinence brief on Resident #1 at 2:00 PM on 05/30/2020, and stated she would not have placed a brief on the resident against his/her will. Further interview with SRNA #2 revealed the SRNA denied calling the resident an idiot. In addition, SRNA #2 denied knowing that the resident's call light had sounded for approximately one hour before receiving assistance. She stated she had asked other staff to notify her if the residents on the unit where Resident #1 resided needed assistance because she was responsible for caring for residents on a different hallway and could not hear Resident #1's call light from there. An interview with SRNA #4 on 06/11/2020 at 12:30 PM revealed on 05/30/2020 at 3:16 PM she and SRNA #5 entered Resident #1's room because the resident's call light was on. According to SRNA #4, the resident did not normally wear incontinence briefs unless he/she was out of bed, but was wearing one on 05/30/2020, and was wet. Interview conducted with SRNA #5 on 06/11/2020 at 12:50 PM, confirmed that she and SRNA #4 assisted Resident #1 on 05/30/2020 because the call light was on. She also stated that the resident only wore an incontinence brief per the resident's request. However, SRNA #5 stated she could not remember if Resident #1 was wearing a brief on 05/30/2020. Interview conducted with the Director of Nursing (DON) on 06/11/2020 at 12:20 PM, revealed she made rounds several times daily to ensure residents were free from abuse and neglect. The DON stated if a resident did not want something it was their right and the staff should not force them. The DON stated Resident #1 should not have had to wear a brief had he/she not wanted to. The DON further acknowledged that approximately one hour was too long to wait for a call light to be answered and stated that SRNA #2 should not have threatened to leave Resident #1's room, nor should any staff member call a resident an idiot. Interview with APRN #1 on 06/10/2020 at 9:25 AM, revealed she assessed Resident #1 on 05/31/2020, the day after the incident. She stated the resident was very upset and told her that the day before, the resident needed to use the restroom, but no one answered the call light and the resident was incontinent. According to the APRN, at the time of the incident, Resident #1 had a Urinary Tract Infection, which caused the resident to urinate frequently. Further interview revealed the resident also told the APRN that SRNA #2 gave the resident a hard time because the resident had peed on himself/herself. According to the APRN, Resident #1 was alert and oriented and she believed the incident occurred as stated by the resident because the resident was so upset and the resident's interviews had remained consistent.

Based on observation, interview, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance, it was determined that the facility failed to properly prevent the possible spread of COVID-19. On 06/09/2020, two (2) Licensed Physical Therapy Assistants (PTAs), one (1) State Registered Nurse Aide (SRNA), two (2) Dietary Aides (DAs), two (2) Cooks, and the Dietary Manager (DM) were all observed not wearing a face mask appropriately in accordance with facility policy and CMS and CDC Guidance. The findings include: A review of COVID-19 Long-Term Care Facility Guidance from CMS dated 04/02/2020 and review of the facility's policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) with a revision date of 04/13/2020, revealed all staff should wear a face mask while they are in the facility. According to CDC guidance for Using PPE, updated on 06/09/2020, when applying a face mask, the nose piece (if the mask has one), should be fitted to the nose with both hands and should be extended under (the) chin. The guidance stated both the mouth and nose should be protected. The guidance also stated that face masks should not be pulled below the chin. 1. Observation during the initial tour on 06/09/2020 at 10:35 AM revealed PTA #1 and PTA #2 were observed in the dining room with their face masks below their noses, leaving their nose exposed. Six (6) residents were observed in the dining room. Interview with PTA #1 on 06/09/2020 at 10:40 AM, revealed he had been trained how to wear his face mask and should have covered his nose with the mask. Interview with PTA #2 on 06/09/2020 at 10:45 AM, revealed he had been trained how to properly wear his face mask and should have had it pulled over his nose. The PTA stated his face mask had slipped down. 2. Observation during initial tour at the Team 2 Unit nurses' station on 06/09/2020 at 10:50 AM, revealed SRNA #1 was observed to be wearing a face mask that was not covering her nose. Two (2) residents were observed in front of the nurses' station. Interview with SRNA #1 on 06/09/2020 at 10:55 AM, revealed she had been trained how to properly don a face mask and was required to wear her face mask while at work. The SRNA stated her mask kept falling down. 3. Observation during initial tour on 06/09/2020 at 10:58 AM, revealed DA #1 and DA #2 were observed walking toward the Team 2 nurses' station. DA #1 was observed to have her face mask under her chin and not covering her nose or her mouth. In addition, DA #2 was observed to have her face mask down below her nose. Two (2) residents were observed at the Team 2 Unit nurses' station. Interview with DA #1 on 06/09/2020 at 11:10 AM, revealed she had been trained how to appropriately don a face mask and was aware that she was required to wear it while she was in the facility. The DA stated she had pushed her face mask down to get a breath of fresh air. Interview with DA #2 on 06/09/2020 at 11:15 AM, revealed her face mask had slipped down and needed to be tightened. 4. Observation during initial tour of the kitchen on 06/09/2020 at 11:05 AM, revealed Cook #1 and Cook #2 were in the kitchen with their face masks not covering their noses. The cooks were in the process of preparing lunch, and food was observed on the preparation table. In addition, the DM was observed to walk through the kitchen with her face mask hanging on her left ear and not covering her nose or her mouth. Interview conducted with the DM on 06/09/2020 at 1:55 PM, revealed she had removed her face mask to talk on a telephone, and failed to put her mask back on after the phone call. Interview with Cook #1 on 06/09/2020 at 1:58 PM, revealed her face mask kept falling down and she should have had ensured it was covering her nose. Interview with Cook #2 on 06/09/2020 at 2:05 PM, revealed her mask needed to be tightened and she should have ensured that her mask was pulled up. An interview with the Director of Nursing (DON) on 06/09/2020 at 2:30 PM, revealed all staff were required to wear a face mask at all times when in the building to help prevent the spread of the Coronavirus. She stated CMS's guidance was initiated on 04/03/2020 and all staff were trained. According to the DON, she made rounds to monitor to ensure staff were following the policy and she was providing on-the-spot education if needed. The DON stated she had not identified any concerns with staff not appropriately donning face masks. An interview with the Administrator on 06/09/2020 at 2:35 PM revealed the Administrator was aware of the CMS Guidance, had revised the facility policy, and implemented the guidance on 04/03/2020. According to the Administrator, all staff were required to wear a face mask when inside the building in accordance with the facility policy to help prevent the spread of the Coronavirus.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure an allegation of abuse was thoroughly investigated per the facility's policy for one (1) of five (5) sampled residents (Resident #1). The facility received an allegation of abuse on 05/30/2020, which alleged State Registered Nurse Aide (SRNA) #2 called Resident #1 an idiot after the resident was incontinent due to waiting for approximately one hour for assistance with toileting. In addition, SRNA #2 told the resident that she would leave the room if the resident cried, and then placed an incontinence brief on the resident against the resident's wishes. The facility conducted an investigation, determined that abuse did not occur, and recommended that SRNA #2 be allowed to return to work with no contact with Resident #1. However, the facility's investigation only consisted of an interview with the alleged perpetrator and an assessment and statement from Resident #1. The facility failed to thoroughly investigate Resident #1's allegation in accordance with facility policy/procedure. The findings include: A review of the facility's policy titled, Abuse Prohibition-Abuse, Neglect, and Misappropriation of Property, undated, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The policy revealed the facility would obtain detailed witness statements from staff working at the time the incident occurred and would submit the witness statements with the incident report. According to the policy, the Administrator was responsible for ensuring all investigations were investigated and policy and procedures were followed. The policy did not address interviewing/assessing other residents. However, interview with the Administrator on 06/10/2020 at 12:15 PM, revealed it was the facility's procedure to interview all interviewable residents and assess all non-interviewable residents to ensure they had not been abused or neglected. A review of Resident #1's medical record revealed the facility admitted Resident #1 on 03/13/2017, with [DIAGNOSES REDACTED]. Review of the resident's most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. A review of a progress note written by Advanced Practice Registered Nurse (APRN) #1 dated 06/02/2020, revealed on 05/30/2020, Resident #1 had reported to the APRN negative verbal speech from SRNA during an episode of urinary incontinence. (Resident #1) stated (he/she) was okay now but that it did hurt (his/her) feelings. An interview with Resident #1 on 06/10/2020 at 9:40 AM, revealed on 05/30/2020, he/she waited for approximately one (1) hour for staff to answer his/her call light, and he/she was incontinent of urine due to the long wait time. Resident #1 stated when SRNA #2 finally responded to the resident's call light and found the resident was incontinent, the SRNA stated to the resident, Why did you do that, you idiot?. Resident #1 stated he/she told SRNA #2 that he/she was incontinent because it had taken so long to answer the call light. The resident with tears in his/her eyes stated, It made me feel really bad and hurt my feelings. Resident #1 stated that SRNA #2 changed the urine-soaked items and proceeded to put an incontinence brief on the resident. Resident #1 stated he/she told the SRNA that he/she did not want a brief; however, the SRNA contained to put a brief on the resident and stated, You have to keep from having another accident. The resident stated he/she then cried because it hurt his/her feelings. According to Resident #1, SRNA #2 threatened to leave the resident's room if he/she cried. Interview with Licensed Practical Nurse (LPN) #2 on 06/11/2020 at 12:15 PM, revealed Resident #1 requested the LPN to come to his/her room at approximately 10:00 PM, shortly after her shift began at the facility on 05/30/2020. The LPN stated Resident #1 reported the abuse/neglect allegation, which had happened on the previous shift at approximately 3:00 PM. The LPN stated SRNA #2 had already completed her shift and had gone home, and she immediately notified the Administrator and the Social Worker (SW), who came to the facility. LPN #2 stated she and the SW interviewed Resident #1 and the resident's story was the same. The LPN stated the SW called SRNA #2 for an interview and placed her on suspension; however, no one had asked her (LPN #2) for a statement, nor interviewed her regarding the resident's allegations. An interview conducted with SRNA #2 on 06/10/2020 at 10:10 AM, revealed she provided care for Resident #1 on 05/30/2020 from 7:00 AM until 3:00 PM. She stated she assisted the resident with incontinence care/toileting approximately every two hours. The SRNA stated at approximately 10:00 AM on 05/30/2020, the resident had an incontinence episode and was about to cry. The SRNA stated she was emotional that day and told the resident if he/she cried, she would leave the room. The SRNA acknowledged that she probably should not have told Resident #1 that she would leave the room. The SRNA stated the resident had also been incontinent when she checked on the resident at 2:00 PM. According to SNRA #2, she put an incontinence brief under the resident at 10:00 AM, without fastening the brief. However, she stated she did not place the brief against the resident's will and denied calling the resident an idiot. Further, SRNA #2 acknowledged that she was aware that Resident #2 required two staff members for assistance with incontinence care/toileting, but other staff members were busy and she did not ask for assistance. Continued interview with SRNA #2 revealed she was not aware that the resident's call light rang for one (1) hour on 05/30/2020. She stated she was working with other residents on another unit and could not hear/see the resident's call light. According to SRNA #2, she was not aware that the resident had any concerns when she left for the day at approximately 3:00 PM on 05/30/2020, but the facility called her after she went home and suspended her employment due to Resident #1's allegations. An interview conducted with SRNA #4 on 06/11/2020 at 12:30 PM, and with SRNA #5 on 06/11/2020 at 12:50 PM revealed they responded to Resident #1's call light on 05/30/2020 at 3:16 PM, just after their shift started. According to SRNA #4, the resident was in bed and wearing an incontinence brief that was wet. SRNA #5 stated she could not remember whether the resident was wearing a brief. Both SRNAs stated the resident did not normally wear a brief while in bed and only wore one per the resident's request when out of bed. SRNA #4 and SRNA #5 stated the facility did not interview them, nor obtain their statement regarding Resident #1. Interview with APRN #1 on 06/10/2020 at 9:25 AM, revealed she assessed Resident #1 on 05/31/2020, the day after the incident, and the resident told her about the incident. The APRN revealed the resident's story remained consistent that he/she was incontinent because no one answered his/her call light. The resident also told the APRN that SRNA #2 gave the resident a hard time because the resident had peed on himself/herself and the resident was very upset about the incident. According to the APRN, Resident #1 was alert and oriented and she believed the incident occurred as stated by the resident because the resident was so upset and the resident's interviews had remained consistent. APRN #1 stated she was aware that the facility was investigating the matter because the facility had notified her of the incident on 05/30/2020; however, the facility did not interview her and she had not spoken with anyone at the facility about the incident. A review of a Resident Abuse Investigation Report Form dated 05/30/2020, revealed the facility investigated Resident #1's allegations and determined the resident was not abused and would allow SRNA #2 to return to work, but not care for Resident #1. Review of the facility's investigation revealed the facility's determination was based on no concerns with the resident's skin assessment, no witnesses to confirm the incident, and after the resident spoke with the APRN he/she was okay. Further review revealed the facility only obtained a statement from SRNA #2 and interviewed Resident #1. There was no documented evidence that the facility obtained statements from staff who worked at the time the incident occurred as required by the facility policy or from the APRN who assessed the resident and documented that the resident's feelings were hurt. Further, there was no evidence the facility assessed/interviewed other residents to determine if they were affected as required by the Administrator. The investigation report was signed by both the SW and the Administrator. An interview conducted with the Social Worker (SW) on 06/11/2020 at 1:00 PM, revealed she was responsible for completing all abuse investigations. The SW revealed staff notified her on 05/30/2020 at approximately 10:00 PM of Resident #1's allegations of abuse and immediately went to the facility to initiate an investigation. She stated she notified SNRA #2 at home that she was suspended and conducted an interview with the SRNA. She further stated that she and LPN #2 interviewed Resident #1. According to the SW, she also interviewed one other resident, Resident A, but did not document the interview, nor did she interview any other residents regarding their care/treatment. In addition, the SW stated she had interviewed staff from another unit, but did not document the interviews, and did not interview staff that worked with SRNA #2 on the unit where Resident #1 resided. The SW stated she had given her report to the Administrator to review prior to sending the final report to state agencies because she only had two (2) days of orientation and this was her first investigation. According to the SW, she was flying by the seat of my pants. Interview with the Administrator on 06/10/2020 at 12:15 PM, revealed he reviewed the SW's final report related to Resident #1. He stated he instructed the SW to interview other interviewable residents, but did not follow up and was not aware that only one (1) resident had been interviewed, nor that the SW had not documented the interview. The Administrator stated because he had only reviewed the SW's final written report, and not all documented evidence, he did not identify that the investigation was not thorough and had agreed with the Social Worker that the allegation was unsubstantiated.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the plan of care for one (1) of five (5) sampled residents (Resident #1). Resident #1's comprehensive care plan required two (2) staff members to provide extensive assistance with toileting and bed mobility. However, interview with State Registered Nursing Assistant (SRNA) #2 revealed she provided incontinence care for Resident #1 on 05/30/2020 at approximately 10:00 AM and 2:10 PM unassisted. In addition, review of Resident #1's toileting care plan, updated 04/07/2020, revealed the resident was to be toileted by staff daily at 9:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 7:00 PM, 9:00 PM, and as needed. However, review of the resident's Restorative Voiding Sheet dated 05/01/2020 through 06/04/2020, revealed the facility failed to toilet the resident as planned sixty (60) times. The findings include: Review of the facility's Purpose of Nursing Care Plans policy, dated September 2017, revealed care plans provide for consistency of care and to allow the nursing team to customize its interventions for each resident. The policy also directed SRNAs to refer to the care plans at the start of their shift and at any time there was a question about a resident's care. According to the policy, staff could utilize more staff than a care plan called for, but may not use less staff than required by the care plan. A review of Resident #1's medical record revealed the facility admitted the resident on 03/13/2017, with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score was thirteen (13) which indicated the resident was interviewable. The MDS also revealed Resident #1 had been assessed to require the extensive assistance of two (2) staff members for bed mobility and toileting. 1. According to Resident #1's SRNA care plan, dated May 2020, the resident required the extensive assistance of two (2) persons for toileting and the resident was continent of both bowel and bladder. Interview conducted with SRNA #2 on 06/10/2020 at 10:10 AM, revealed she was aware that Resident #1 required the extensive assistance of two (2) staff persons for toileting and bed mobility. However, on 05/30/2020, the SRNA provided incontinence care while the resident was in bed at 10:00 AM, and between 2:10 PM and 2:15 PM, alone, and did not have another staff member assist with the resident's care. According to SRNA #2, all other SRNAs were busy and she did not ask a nurse for assistance. 2. Review of Resident #1's comprehensive care plan, restorative toileting care plan, updated 04/07/2020, revealed staff were required to toilet the resident daily at 9:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 7:00 PM, 9:00 PM, and as needed. Review of a Restorative Voiding Sheet dated 05/01/2020 through 06/04/2020, revealed Resident #1 had not been toileted as required by the resident's care plan on 60 occasions from 05/01/2020 through 06/04/2020. Interview conducted with SRNA #6 on 06/10/2020 at 9:45 AM, revealed she was required to review the care plan for residents at the beginning of every shift, and stated she was aware that the resident was on a toileting program and that she was required to toilet the resident at specific times and as needed. According to the SRNA, she was unaware Resident #1 was not being toileted at the times directed by the care plan. An interview with SRNA #7 on 06/10/2020 at 10:00 AM, revealed she was also aware that staff were required to check residents' care plans at the beginning of every shift. The SRNA confirmed that Resident #1 was on a toileting plan and stated that she thought she had been toileting Resident #1 as directed. Interview with Licensed Practical Nurse (LPN) #2 conducted on 06/11/2020 at 12:10 PM, revealed she had developed the toileting care plan for Resident #1 and staff were required to review resident care plans at the beginning of every shift. The LPN further stated that the resident required the extensive assistance of two (2) persons for toileting and incontinence care. The LPN stated she reviewed the Restorative Voiding Sheets monthly to ensure staff were completing the forms as directed and had not identified that staff were not toileting Resident #1 as directed by the care plan. Interview conducted with the Director of Nursing (DON) on 06/11/2020 at 12:20 PM, revealed she made rounds several times daily to ensure residents were receiving care as directed by the residents' care plans. The DON stated she had not identified any concerns with residents not receiving the care as directed by their care plans.

Based on interview, record review, review of a facility investigation, and review of the Administrator's job description, it was determined that the facility failed to be administered in a manner that enabled it to attain or maintain the highest practicable physical well-being of each resident. According to the Administrator's job description and the abuse policy, he was responsible for the competence of the workforce and was responsible to ensure all abuse/neglect investigations were investigated and policy and procedures followed. However, the Administrator designated the Social Worker to complete resident abuse/neglect investigations without ensuring she was competent to do so. Subsequently, the Social Worker failed to thoroughly investigate Resident #1's allegation of abuse/neglect on 05/30/2020. The findings include: Review of the Administrator's job description, not dated, revealed the primary purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to provide excellent care to residents. The job description also revealed the Administrator would review and frequently check the competence of the workforce. A review of the facility's policy titled, Abuse Prohibition-Abuse, Neglect, and Misappropriation of Property, undated, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The policy revealed the facility would obtain detailed witness statements from staff working at the time the incident occurred and would submit the witness statements with the incident report. Further review revealed the policy did not address interviewing/assessing other residents when conducting an investigation. However, interview with the Administrator on 06/10/2020 at 12:15 PM, revealed it was the facility's procedure to interview all interviewable residents and assess all non-interviewable residents to ensure they had not been abused or neglected. Further review of the abuse policy revealed the Administrator or his designee would investigate all alleged incidents of abuse. However, the policy revealed it was ultimately the Administrator who was responsible to ensure all investigations were investigated and policy and procedures followed. Interview with the Administrator on 06/10/2020 at 12:15 PM, revealed he had designated the facility Social Worker to complete facility abuse/neglect investigations and the Social Worker had investigated an allegation made by Resident #1. Review of the Social Worker's employee file revealed the facility hired the Social Worker (SW) on 09/16/2019. However, there was no documented evidence in the employee's file that the SW had been trained on how to conduct an abuse/neglect allegation. The surveyor requested that the Administrator provide a copy of the SW's education on 06/12/2020 at 10:50 AM; however, the facility provided no training evidence. Review of a Resident Abuse Investigation Report Form dated 05/30/2020, revealed the facility Social Worker investigated an allegation that SRNA #2 called Resident #1 an idiot when the resident was incontinent after waiting for approximately one hour for staff to respond to his/her call light; that SRNA #2 placed an incontinence brief on Resident #1 against his/her will; and that SRNA #2 told the resident that if he/she cried, the SRNA would leave the room. According to the investigation, the SW interviewed SRNA #2 and Resident #1, and an assessment of Resident #1 was completed. Review of the facility's final investigative report revealed the facility determined that SNRA #2 did not abuse Resident #1 and planned to allow SRNA #2 to return to work with no contact with Resident #1. According to the report, the decision was based upon no witnesses being found to confirm the incident; however, there was no documented evidence that staff who worked during the incident, or any staff, was interviewed in accordance with facility policy. Further review revealed the facility's decision to unsubstantiate was based upon no concerns being identified with Resident #1's skin assessment, and that the resident was okay after he/she spoke with APRN #1. However, there was no evidence that the facility interviewed the APRN or considered that the APRN documented that the resident's feelings were hurt. (Refer to F610.) The report was signed by the SW and the Administrator. Interview with the Social Worker (SW) on 06/10/2020 at 11:30 AM, revealed the investigation involving Resident #1 was the first investigation that she had completed since her employment at the facility. The SW stated she only received two (2) days of orientation when she was hired and was flying by the seat of my pants when she conducted the investigation. According to the SW, she asked the Administrator to review the investigation before submitting the documentation to state agencies to ensure the investigation was complete and accurate; however, he only advised her to interview another resident (no documented evidence that it was completed). Interview with the Administrator on 06/10/2020 at 12:15 PM, confirmed that he was ultimately responsible for ensuring abuse allegations were investigated thoroughly. The Administrator also confirmed that the social worker asked for assistance with the investigation and he had instructed the SW to interview interviewable residents. However, he did not follow up and stated he was not aware that the SW only interviewed one resident, nor that the interview was not documented. According to the Administrator, the SW had received two (2) weeks of training with the previous SW and he was not aware that she did not feel comfortable conducting investigations. Further interview revealed the Administrator was not aware that this was the SW's first investigation, and he only read the SW's final report and did not review witness statements or any other documentation. Subsequently, the Administrator did not identify that the SW did not interview other staff and residents and document the interviews, nor that all non-interviewable residents were not assessed to ensure they had not been abused or neglected. The Administrator stated that based on the final report, he agreed with the SW that the allegation was unsubstantiated, but was not aware at the time that the investigation was not thorough.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure an allegation of abuse was reported, no later than two (2) hours, to the facility Administrator and other officials in accordance with State law, that involved Resident #1. Interview with State Registered Nurse Aide (SRNA) #1 on 11/05/18 revealed she witnessed SRNA #2 being rough with Resident #1 at approximately 11:00 PM on 10/29/18. SRNA #1 failed to report the incident to Administrative staff until 10/30/18, the following day, at approximately 4:30 PM. The findings include: Review of the facility policy titled Abuse Prohibition, not dated, revealed the facility would uphold residents' right to be free from verbal, sexual, physical, and mental abuse. The policy further stated the Administrator or Designee would be immediately notified and was required to report all allegations of abuse immediately to the required State designated agencies. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Annual Minimum Data Set (MDS) assessment completed 08/15/18 revealed the resident required limited assistance of one (1) staff member with personal hygiene and toileting. The resident's Brief Interview for Mental Status (BIMS) score was (00) which revealed he/she was not interviewable. An interview was attempted on 11/05/18 at 12:00 PM with Resident #1; however, the resident was unable to participate related to his/her cognitive impairment. Interview with SRNA #1 on 11/05/18 at 12:20 PM revealed she witnessed SRNA #2 being rough with Resident #1 when she transferred him/her to the commode at approximately 11:00 PM on 10/29/18. However, the SRNA failed to report the alleged abuse to Administrative staff until 10/30/18 at approximately 4:30 PM. SRNA #1 stated she should have reported the alleged abuse to the charge nurse and/or Administrative staff immediately as she had been trained to do. Interview with the Administrator on 11/05/18 at 4:00 PM confirmed SRNA #1 failed to immediately report an allegation of abuse that involved Resident #1. He stated that he and the Director of Nursing (DON) were not notified of the incident, which allegedly occurred on 10/29/18, until approximately 4:30 PM on 10/30/18. The Administrator stated that facility staff had been trained to report allegations of abuse immediately, and that SRNA #1 should have immediately notified the charge nurse and/or Administrative staff when the incident occurred on 10/29/18.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice in two (2) of three (3) medication carts. Observation of medication carts revealed fifty (50) blue top laboratory collection tubes, one hundred (100) [MEDICATION NAME] flushes (treats or prevents blood clots), five (5) wound dressings, thirty-two (32) [MEDICATION NAME] Tartate tablets (blood pressure medication), and one hundred twenty (120) [MEDICATION NAME] (anxiolytic medication) tablets that were expired and available for use. In addition, the [MEDICATION NAME] syringes were not labeled with a resident name or prescribing information and two (2) bottles of insulin were not dated when they were opened. The findings include: Review of the facility's policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/16, revealed the facility should ensure that expired medications and biologicals were stored separately from other medications until destroyed or returned to the pharmacy or supplier. The policy also revealed once any medication or biological was opened, facility staff should record the date opened on the medication container and should follow manufacturer/supplier guidelines with respect to expiration dates. Observation of Team 1's medication storage on 06/07/18 at 1:16 PM revealed 50 anticoagulation serum collection vials that expired in (MONTH) and (MONTH) (YEAR), 100 5-milliliter syringes of [MEDICATION NAME] that contained 10 units per milliliter that expired from (MONTH) to (MONTH) (YEAR), and five wound care dressings that expired in 2014. Observation revealed the [MEDICATION NAME] syringes were also not labeled with a resident name or prescribing information. Observation of Team 2's medication storage on 06/07/18 at 2:50 PM revealed an opened vial of [MEDICATION NAME] R insulin and [MEDICATION NAME]that were not dated when they were opened. Further observation of Team 2's medication cart on 06/07/18 at 4:55 PM revealed two [MEDICATION NAME] Tartate 24-milligram tablets that expired on 05/31/18. Observation of Team 3's medication cart on 06/07/18 at 5:40 PM revealed 120 [MEDICATION NAME] HCL 15-milligram tablets and 30 [MEDICATION NAME] Tartate 24-milligram tablets that expired on 05/31/18 and were available for use in the medication cart. Interview with the Pharmacist on 06/07/18 at 2:46 PM revealed the pharmacy did not label individual [MEDICATION NAME] syringes, but labeled the medication box that contained the syringes with the resident's information. Interview with the Director of Nursing (DON) on 06/07/18 at 3:37 PM revealed staff were required to audit the medication room on Sunday night to remove medications before they expired. The DON further stated the auditing was not being done thoroughly and as required.

Based on observation, interview, and review of the facility policy it has been determined the facility failed to provide two (2) of thirty-one (31) sampled residents with reasonable accommodations to meet resident needs. Resident #64 was observed to have the call light on the floor on all observations made during the survey. Resident #37 was observed to have the call light placed out of reach and inaccessible. The findings include: The facility did not have a policy regarding call lights. Review of Resident #64's medical record revealed the facility admitted the resident on 08/14/17 with [DIAGNOSES REDACTED]. Review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. The MDS also revealed the resident required extensive assistance of two (2) or more persons to transfer from bed to chair, and for toileting and bathing. Further review of the MDS revealed the resident required extensive assistance of one (1) or more persons for personal hygiene. Observation of Resident #64 on 06/05/18 at 3:12 PM revealed the resident's call light was on the floor and out of the resident's reach. The resident stated she could reach it with the hairbrush. Observation of Resident #64 on 06/06/18 at 9:33 AM revealed the resident was lying in bed and the resident's call light was observed on the floor. Observation of Resident #64 on 06/06/18 at 10:14 AM revealed the resident was awake and the resident's call light remained on the floor. An interview with the resident revealed if the resident needed help or assistance, I guess I would have to fall out of the bed. Further interview with the resident revealed he/she had heard the facility's announcement for a smoke break, but was not able to let them know that he/she wished to smoke. The surveyor asked staff to take the resident for a smoke break. Observation of Resident #64 on 06/07/18 at 8:34 AM and 9:27 AM revealed the resident was in bed and the resident's call light was on the floor, out of the resident's reach. Interview with State Registered Nurse Aide (SRNA) #4 on 06/07/18 at 9:55 AM revealed staff should monitor a resident's access to call lights every time they enter the room and during rounds. Interview with SRNA #5 on 06/07/18 at 10:02 AM revealed residents should be assessed to ensure they have access to their call light every time staff round on the residents. The surveyor asked staff to observe Resident #64's call light, and the SRNA picked up the resident's call light and clipped it to the resident's gown. 2. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09, with [DIAGNOSES REDACTED]. Review of Resident #37's MDS assessment dated [DATE] revealed the resident had a BIMS score of 10, indicating the resident had moderately impaired cognition. Observation on 06/07/18 at 1:25 PM revealed Resident #37 was sitting in a Geri-Chair yelling, Help me! The resident's call light was observed clipped to the back of the resident's left shirt sleeve. An interview with the resident revealed the resident did not know where his/her call light was located. When the resident was shown where the call light was located, the resident could not reach the call light. Interview on 06/07/18 at 1:25 PM with SRNAs #4 and #5 revealed they were not aware the resident was unable to reach the call light when it was clipped to the back that of the resident's shirt. Interview with the Director of Nursing (DON) on 06/07/18 at 3:24 PM revealed it was her expectation that all residents would have access to a call light because it was the residents' avenue for communication to ensure residents' needs were met promptly and without delay. She stated when SRNAs/Nurses made rounds they should check to ensure residents were able to access their call light. According to the DON, the facility did not monitor to ensure call lights were accessible.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the physician for one (1) of thirty-one (31) sampled residents (Resident #37) when the resident had a need to alter treatment significantly. Resident #37 had a physician's order for [MEDICATION NAME] (a laxative) to treat constipation. The facility failed to notify Resident #37's physician of a need to alter treatment when the resident began having two to three bowel movements per day in (YEAR). The findings include: Review of the facility policy and procedure titled Notification of Changes in A Resident's Condition, not dated, revealed that all changes in the resident's medical condition must be reported to the physician as soon as practical, but in no case should notification exceed twenty-four (24) hours. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09 with [DIAGNOSES REDACTED]. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Interview on 06/06/18 at 9:48 AM with Resident #37 revealed the resident had been having diarrhea for over one month. Review of Resident #37's physician orders dated 02/19/18 revealed the resident had an order for [REDACTED]. Review of the intake/output summary from 04/30/18 through 06/06/18 for Resident #37 revealed the resident had two to three bowel movements per day. Continued review of Resident #37's physician orders revealed an order dated 05/31/18 to collect a stool specimen for [MEDICAL CONDITION] (C. diff) because the resident was pooping too much and to administer [MEDICATION NAME] HCL (used to treat diarrhea). However, review of laboratory results for the resident revealed the resident's stool specimen was negative for [DIAGNOSES REDACTED]. Review of Resident #37's Medication Administration Record [REDACTED]. Interview on 06/06/18 at 2:37 PM with State Registered Nurse Aide (SRNA) #2 revealed Resident #37 had been having approximately three bowel movements each day for the past month and had three loose bowel movements since breakfast that morning. Interview on 06/06/18 at 2:44 PM with Licensed Practical Nurse (LPN) #3 revealed the night shift nurse was required to review all resident output records daily. She stated Resident #37's medical doctor should have been notified that the resident was having two to three bowel movements per day. She stated she was unaware the resident was having two to three bowel movements per day. Interview on 06/07/18 at 3:01 PM with the Director of Nursing (DON) also revealed the night shift nurse was responsible for reviewing all resident output records. The DON stated that Resident #37's physician should have been notified when the resident was having two to three bowel movements daily so the [MEDICATION NAME] dosage could have been decreased. Interview on 06/07/18 at 2:30 PM with Resident #37's physician revealed he prescribed [MEDICATION NAME] for the resident for constipation. He stated he had not been notified that the resident was having two to three bowel movements daily. The physician stated if he had been notified he would have decreased the medication to use as necessary (PRN).

Based on observation, interview, and record review, it was determined the facility failed to provide a homelike environment for two (2) of thirty-one (31) sampled residents (Resident #10 and Resident #46). Observation of Resident #10 and Resident #46's bed rails revealed the foam pipe insulation/black electrical tape used to pad the residents' bed rails was loose and frayed. The findings include: Review of the facility policy and procedure titled Use of Side Rail Padding revealed side (bed) rail padding was used for safety interventions and as necessary for prevention of skin tears/bruises. The policy stated staff would monitor side rail padding on a daily basis. Further review of the policy revealed the padding would be cleaned as needed according to the housekeeping cleaning schedule, and Maintenance would be notified when any replacement was needed. Review of the facility policy and procedure titled Cleaning of beds and bed rails revealed housekeeping staff were assigned to clean resident rooms every day. The policy stated staff would wipe down immediate touch areas in the rooms, and if side rail padding was damaged, Maintenance would be informed. According to the policy, Maintenance staff was responsible for changing padding. 1. Review of Resident #46's medical record revealed the facility admitted the resident on 05/05/16, with [DIAGNOSES REDACTED]. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) could not be completed. Further review of the MDS revealed the resident was totally dependent on staff for activities of daily living. On 06/06/18 at 10:07 AM, an interview was attempted with Resident #46; however, the resident was unable to answer questions. Observation revealed the resident utilized two (2) upper bed rails that were covered with foam pipe insulation that was torn and frayed. Interview on 06/06/18 at 10:37 AM with State Registered Nurse Aide (SRNA) #2 revealed the facility placed foam pipe insulation on Resident #46's bed rails to protect (his/her) skin because the resident sometimes became agitated and moved his/her legs and arms wildly. SRNA #2 stated if she noticed a problem with the foam, she was required to notify a nurse or Maintenance staff. Interview on 06/07/18 at 2:00 PM with Housekeeper #5 revealed if she noticed a problem with the foam padding when she cleaned bed rails, she would have notified Maintenance staff. Interview on 06/07/18 at 3:01 PM with the Director of Nursing revealed foam padding was used to help protect residents from injury. She stated it was everyone's responsibility to let Maintenance staff know if the foam padding became torn so the padding could be replaced. 2. Observation of Resident #10's bed on 06/06/18 at 9:34 AM revealed the resident had quarter bed rails that were padded with foam pipe insulation which was covered with black electrical tape that was loose and frayed. Interview with the Director of Nursing (DON) on 06/07/18 at 3:45 PM revealed the resident's rails were padded to prevent injuries because the resident had fragile skin. According to the DON, she was not aware the resident's bed rail padding was in need of repair or replacing. Further interview with the DON revealed managers were required to make rounds in the facility to identify concerns with resident equipment, and if concerns were identified they were required to notify Maintenance of the need to repair or replace the equipment. Interview with the Maintenance Director on 06/07/18 at 4:35 PM revealed he placed foam pipe insulation with electrical tape on Resident #10's bed rails. He further stated staff were required to report concerns to him; however, he had not been notified that the padding was loose/frayed.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide respiratory care consistent with physician orders for one (1) of thirty-one (31) sampled residents. Resident #37 had a physician's order for oxygen at four (4) liters. The facility failed to ensure oxygen was provided to the resident. The findings include: Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09 with [DIAGNOSES REDACTED]. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Further review revealed Resident #37 had a physician's order for oxygen to be administered at 4 liters via nasal cannula. Observation on 06/05/18 at 10:30 AM revealed Resident #37 was in the activity room sitting at the head of the table. The resident was not utilizing oxygen. Interview with Resident #37 on 06/06/18 at 9:48 AM revealed the resident stated he/she was supposed to receive oxygen at 4 liters. The resident stated he was not able to reach the oxygen concentrator to turn his/her oxygen up or down. Observation on 06/06/18 at 3:03 PM revealed Resident #37 was lying in bed. The resident's oxygen concentrator was observed to be delivering no oxygen to the resident (set at zero). Further observation on 06/07/18 at 1:25 PM, revealed Resident #37 was sitting in a chair to the right side of his/her bed looking out the window. The resident's oxygen tubing was lying on the left side of the bed and not within reach of the resident. Interview with State Registered Nurse Aide (SRNA) #2 on 06/06/18 at 2:37 PM revealed the SRNAs could not operate oxygen concentrators; however, if they noted a concern, they would notify the resident's nurse. Interview on 06/07/18 at 3:30 PM with the Director of Nursing (DON) revealed Resident #37 should have received oxygen per the physician orders.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare and serve food under sanitary conditions. Observations on 06/05/18 and 06/07/18 revealed the hand washing sink in the kitchen was clogged and not draining water when staff washed their hands. The findings include: A review of the facility policy titled Sanitation, undated, revealed facility equipment would be maintained in a sanitary manner and dietary inspections would be performed on a routine basis. Observation of the hand washing sink during the initial kitchen tour on 06/05/18 at 10:00 AM, revealed the sink was not draining and had standing water in it while kitchen staff who were preparing the lunch meal were washing their hands. Observations of the hand washing sink during the kitchen sanitation tour conducted on 06/07/18 at 2:30 PM revealed the hand washing sink continued to have standing water in it and was not draining during hand washing. Interview with the Dietary Manager on 06/07/18 at 2:42 PM revealed she was responsible to monitor sanitary conditions in the kitchen daily and was aware the hand washing sink was not draining. The Dietary Manager stated she had informed Maintenance of the problem on the morning of 06/07/18, and Maintenance had observed the sink and placed drain cleaner in it; however, the sink continued to not drain. Interview with the Maintenance Director on 06/07/18 at 3:01 PM revealed he had placed drain cleaner in the sink earlier in the day, but stated the drain pipes were old and it may take a while to open the drain. However, there was no further evidence found to indicate the facility had taken further action to correct the problem.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure accuracy of the medical record for one (1) of thirty-one (31) sampled residents (Resident #37). Review of Resident #37's plan of care revealed the resident was to be administered oxygen at two (2) liters per minute. However, review of the physician's orders [REDACTED]. The findings Include: Interview with the Director of Nursing on 06/07/18 at 4:15 PM revealed the facility did not have a policy related to ensuring the accuracy of documentation in resident records. Review of the facility's policy, CNA Careplan, undated, revealed when a new physician's orders [REDACTED]. In addition, at the end of the month the policy stated that Minimum Data Set (MDS) staff would ensure that all physician orders [REDACTED]. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/18 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. However, review of Resident #37's most recent CNA careplan instructed staff that the resident's oxygen was to be administered at 2 liters per minute. Interview on 06/07/18 at 3:10 PM with the Director of Nursing (DON) revealed when a new physician's orders [REDACTED]. The DON further stated that at the end of each month the MDS Coordinator was responsible to ensure that current physician orders [REDACTED]. Interview on 06/07/18 at 4:35 PM with the MDS Coordinator revealed she was responsible for reviewing resident care plans at the end of the month to ensure that they accurately reflected physician orders. However, the MDS Coordinator stated it had been overlooked that Resident #37's physician's orders [REDACTED].

Based on observation, interview, record review, review of facility policy, and review of the facility's investigation it was determined the facility failed to have an effective system in place to ensure one (1) of three (3) sampled residents (Resident #1) was free from abuse. On 01/13/16, Resident #1 reported to Registered Nurse (RN) #1 that boy (State Registered Nurse Aide #1) was going to take his/her food stamps (a known behavioral trigger for Resident #1). The resident demonstrated to the RN how the State Registered Nurse Aide (SRNA) stuck his middle finger up at him/her and put his hands in his/her face. The resident stated the incident happened last night (on 01/13/16 at approximately 3:00 AM). SRNA #2 reported for work at 3:00 PM on 01/13/16 and at this time she reported to RN #1 that during the 3:00 AM rounds on 01/13/16 she witnessed SRNA #1 taunt and agitate Resident #1 about the resident's food stamps. SRNA #2 stated she witnessed SRNA #1 place both his middle fingers in the resident's face. Further review of the facility's investigation revealed facility staff interviewed Resident #1 on 01/13/16 (time not documented) regarding the incident and the resident referred to that boy stating he put his hands in my face and demonstrated to staff by sticking up his/her middle finger and described the act as being sexual. The resident was asked by staff if the male had hurt him/her and he/she replied, No, just threatened me. The facility investigation stated SRNA #1 was placed on suspension pending the investigation. Facility staff failed to immediately report the allegation when it occurred and failed to take action when it was reported by the resident. Furthermore, the facility failed to consider the resident's initial report of the incident, the resident's initial interview, when they determined the incident to be a he said, she said incident. The facility decided to place SRNA #1 (alleged perpetrator) on day shift so he could be closely monitored. However, there was no evidence the facility closely monitored SRNA #1 and after one day the SRNA returned to work on night shift, unsupervised. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/29/16 and determined to exist on 01/13/16 at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280). The facility was notified of the Immediate Jeopardy on 01/29/16. An acceptable Allegation of Compliance was received on 02/10/16, which alleged removal of the Immediate Jeopardy on 02/10/16. A partial extended survey was conducted on 02/11/16. The State Survey Agency determined the Immediate Jeopardy was removed on 02/10/16, which lowered the Scope and Severity to D at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Abuse Prohibition-Abuse, Neglect, and Misappropriation of Residents' Property, undated, revealed the facility upholds resident rights to be free from abuse and strictly prohibits verbal, sexual, physical, and mental abuse of residents. The policy stated residents shall not be subject to abuse by anyone and it was the policy of the facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse, misappropriation of residents' property, or injury of unknown origin. The policy defined verbal abuse as any use of oral, written, or gestured language that included disparaging and derogatory terms to residents. Further review revealed any report or suspicion of an incident was to be reported immediately to the charge nurse. Review of Resident #1's medical record revealed the facility admitted the resident on 12/22/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/01/16, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 3, indicating the resident was severely cognitively impaired. Review of the resident's care plan, dated 10/04/13, with a target date of 03/24/16 (no review date) revealed the resident was at risk to be socially inappropriate, with interventions that included for caregivers to provide opportunity for positive interaction and attention. Further review of the record revealed a readmission care plan, dated 12/25/15, which stated the resident was at risk for behavioral symptoms. Interventions included for staff to keep the resident's environment calm and relaxed. Interview with SRNA #1 on 01/27/16 at 1:30 PM, SRNA #2 on 01/27/16 at 3:25 PM, RN #1 on 01/27/16 at 4:21 PM, Licensed Practical Nurse (LPN) #2 on 01/29/16 at 11:33 PM, and the Activities Director on 01/29/16 at 11:38 AM revealed Resident #1 would often (once monthly) become upset about not receiving his/her food stamps and Social Security check. Interviews conducted on 01/27/16 with the Director of Nursing (DON) at 3:40 PM, LPN #3 at 4:00 PM, and RN #1 at 4:21 PM revealed the resident had been sexually abused as a child and often verbalized the details of the abuse. LPN #3 stated that when Resident #1 was interviewed by facility staff on 01/13/16 about the incident, the resident described the act of SRNA #1 sticking his middle fingers in his/her face as being sexual. Interview with RN #1 on 01/27/16 at 4:21 PM revealed on 01/13/16 around lunchtime (exact time unsure) Resident #1 reported to her that the night before that boy (SRNA #1) told him/her that he was going to take his/her food stamps. The resident then demonstrated how that boy stuck his middle fingers in his/her face. The RN stated she did not report the allegation at that time because Resident #1 was unable to give a description of the male. However, interview with RN #1 revealed SRNA #1 was the only male working on the resident's hall the morning of 01/13/16. Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed she and SRNA #1 were responsible for caring for Resident #1 during the morning of 01/13/16. SRNA #2 stated both she and SRNA #1 were in Resident #1's room during the 3:00 AM rounds when she witnessed the incident occur. SRNA #2 stated during the 3:00 AM round SRNA #1 began to taunt Resident #1 stating I got your food stamp card. The SRNA stated Resident #1 became agitated and yelled at SRNA #1 to leave his/her room. SRNA #2 stated she witnessed SRNA #1 walk up to the resident and put both of his middle fingers in the resident's face. SRNA #2 stated she did not report the incident at the time it occurred because following the incident she became busy with another resident. SRNA #1 stated she did not report the incident until returning to work later that afternoon for the 3:00 PM shift on 01/13/16. SRNA #2 stated she reported the incident to RN #1. Interview with RN #1 on 01/27/16 at 4:21 PM revealed after SRNA #2 returned to work on the afternoon of 01/13/16, the SRNA reported the incident to her and an investigation was started. The RN stated the SRNA told her almost verbatim what Resident #1 had reported to her earlier that day. The RN stated as soon as SRNA #2 told her about the incident she . knew it had to be true. Further interview revealed the RN felt like SRNA #1 was instigating Resident #1 because he knew it would upset the resident to taunt him/her about the food stamps. The RN stated she was shocked SRNA #1 was allowed to return to work after the incident was reported. Review of the facility's investigation, dated 01/13/16, revealed LPN #3 interviewed Resident #1 regarding the incident. Review of the Witness Statement Form, dated 01/13/16, revealed when facility staff asked Resident #1 about that boy the resident stated he put his hands in my face and demonstrated to LPN #3 by sticking up his/her middle finger. The resident further described the act of SRNA #1 sticking his middle fingers in his/her face as being sexual. When asked by LPN #3 if that boy had ever hurt him/her, the resident stated, No, just threatened me. The facility's investigation stated the resident was unable to give a description of that boy. Interview with LPN #3 on 01/27/16 at 4:00 PM revealed she was responsible to interview Resident #1 regarding the alleged incident. The LPN stated when questioned about the incident Resident #1 was able to demonstrate with both hands how that boy stuck his middle fingers in his/her face. Interviews with unsampled Residents B and C (whom the facility assessed to be cognitively intact) conducted on 01/27/16 at 11:40 AM, revealed both residents had overheard SRNA #1 (alleged perpetrator) yell at Resident #1 on different occasions (dates unknown). Resident B stated he/she had overheard SRNA #1 yell for Resident #1 to shut up. Resident C stated he/she had overheard SRNA #1 yell and mock Resident #1. The residents stated that the facility interviewed them about staff treatment; however, they did not ask questions regarding SRNA #1's treatment of [REDACTED].#1, including Resident B and Resident C. Interviews conducted on 02/11/16 with the RN Supervisor at 12:20 PM and LPN #3 at 12:39 PM revealed they conducted the resident interviews; however, they did not ask specific questions regarding care provided by or concerns with SRNA #1. Further review of the facility's investigation revealed SRNA #1 was not working at the time the investigation was initiated and was placed on suspension pending the results of the investigation. The investigation stated, None of the staff have ever witnessed an inappropriate behavior from (SRNA #1); however, the investigation also noted that SRNA #2 stated that she saw SRNA #1 taunt the resident and put his middle fingers in the resident's face. The investigation further stated that the resident was unable to give a description of the person and unable to recall the incident, even though Resident #1 initially reported the incident and gave the same account when the resident was initially interviewed by staff. The facility failed to consider Resident #1's initial report of the incident, Resident #1's initial interview, and failed to identify concerns from other residents' interviews that lived on the same hallway as Resident #1 when they determined the allegation was a he said, she said incident. The investigation stated SRNA #1 was placed on dayshift where he would be closely monitored. Review of SRNA #1's time clock record revealed the SRNA returned to work on 01/21/16 on day shift. However, further review of time clock records revealed SRNA #1 worked on 01/23/16, 01/24/16, and 01/25/16 during night shift, unsupervised. Observations made on 01/27/16 revealed SRNA #1 working in the facility on day shift. No evidence was found during observation of SRNA #1 that he was being closely monitored. Interviews with the Director of Nursing (DON) on 01/27/16 at 5:45 PM, RN #2 on 01/27/16 at 6:50 PM, the MDS Coordinator on 01/28/16 at 12:11 PM, RN #3 on 01/28/16 at 12:26 PM, and LPN #1 on 01/28/16 at 12:30 PM revealed the facility did not have a system in place to closely monitor SRNA #1 when he returned to work. Interview with the Administrator on 01/28/16 at 4:28 PM revealed he was not aware SRNA #1 had worked night shifts after returning from suspension. The Administrator stated that a monitoring system had not been put in place to closely monitor SRNA #1. Interview with the DON on 01/29/16 at 11:45 AM revealed the facility failed to follow their own policy to ensure allegations of abuse were reported and investigated immediately. The DON stated when the incident was witnessed it should have been reported to Administrative staff as well as after Resident #1 reported the allegation to staff on 01/13/16 during lunch. Although the facility's investigation revealed Resident #1 reported the allegation on two occasions and the incident was witnessed by facility staff, the facility failed to substantiate the allegation and allowed SRNA #1 to return to work. The facility failed to implement its policy to ensure Resident #1 and other residents were protected from potential abuse. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/10/16. The facility implemented the following actions to remove Immediate Jeopardy: 1) On 02/04/16, a team that included the Administrator, Director of Nursing (DON), Social Services Director (SSD), Registered Nurse (RN) Supervisor, Restorative Supervisor, Minimum Data Set (MDS) Coordinator, and MDS Coordinator Assistant reviewed the facility's investigation regarding Resident #1 to determine the cause(s) of the Immediate Jeopardy (IJ) and to implement corrective action. The team determined the causes of IJ to include: a. Not reporting the allegation in a timely manner per facility policy. b. Not completing a thorough investigation. c. The accused staff member was allowed to return to work prior to a thorough investigation being completed. d. Resident #1's care plan was not updated to include new behaviors or concerns. The team determined Resident #1 was the only resident impacted by the alleged incident; however, any facility resident could have been impacted. The facility is divided into three nursing areas: Team 1, Team 2, and Team 3. Resident #1 resided on Team 2, where the accused staff member worked. The DON completed the investigation of the initial allegation and identified the following employees as being involved: SRNA #1, SRNA #2, and RN #1. 2) An Abuse and Neglect Inservice was compiled by the SSD from federal regulations to include: a. What abuse means b. Types of Abuse c. Who is responsible for reporting allegations d. Who allegations are reported to e. Time frames to report allegations in f. Suspension of accused employee g. Disciplinary actions for failure to report according to the abuse policy h. How to protect the resident after the allegation is made The team (Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) was in-serviced on Abuse and Neglect by the SSD on 02/01/16. 3) Facility staff began in-service training on Abuse and Neglect on 02/01/16. The in-service training was given by the DON, SSD, RN Supervisor, Restorative Supervisor, and MDS Coordinator Assistant. All facility staff completed the Abuse and Neglect In-service training by 02/04/16. A posttest was completed by all staff after completing the in-service training with a 100% pass rate. 4) Facility charge nurses were in-serviced by the DON and RN Supervisor on the Addendum of Notification Protocol by 02/09/16. The in-service included who to notify in a case of suspected abuse or injury of unknown origin. 5) During the hiring process, all new staff will be in-serviced by the DON and SSD to include: a. Reporting Abuse and Neglect b. Care planning Behaviors c. Documenting Behaviors All staff will receive a bi-annual in-service training on Abuse and Neglect by the SSD. 6) To ensure a complete investigation the SSD developed an Assessment Tool to monitor compliance with resident rights and an Assessment Tool to document the resident and staff interviews. a. Five different residents throughout the building (with a Brief Interview for Mental Status score of 8 or above) will be interviewed by the SSD weekly for concerns of abuse or neglect. b. Five different employees will be interviewed by the SSD weekly to verify their comprehension and compliance with the facility Abuse and Neglect policy. Any allegations of abuse or neglect are to be addressed immediately per facility policy by the SSD. 7) Any incidents of abuse or neglect will be listed on the 24-hour report sheet. Starting 02/05/16 all 24 Hour Report Sheets and physician's orders [REDACTED]. Any issues or concerns will be reported during the daily Department Head Meeting. 8) During the daily Department Head Meetings, all allegations of abuse or neglect will be reviewed by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 9) On a daily basis, all resident behavior sheets are reviewed by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant for unusual behaviors. Any new behaviors or concerns will be care planned immediately by the MDS Coordinator and MDS Coordinator Assistant. 10) During the weekly Quality Assurance (QA) meeting all non-interviewable (Brief Interview for Mental Status score less than 8) residents' skin assessments are reviewed for injuries of unknown origin by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 11) An Investigation Check List was compiled by the DON and SSD to ensure investigations were completed according to facility policy. The checklist included: a. Who was notified of the alleged abuse. b. Who completed the investigation. c. Who reviewed the information prior to closing the investigation. A more complete history of the resident involved, to include: cognitive function, Brief Interview for Mental Status (BIMS) score, and any pertinent medical and psychiatric history. All investigations are to be completed by the SSD or the DON. All past facility investigations (since last survey in April 2015) were reviewed by the SSD on 02/09/16. The SSD used the Investigation Check List and the facility's Abuse and Neglect policy to review the investigations to ensure a thorough investigation had been completed. 12) All Department Managers were in-serviced on the Investigation Check List by the SSD or DON on 02/05/16. 13) An Investigation Protocol Check List was developed by the SSD and DON to assist during the beginning of any abuse or neglect investigation. The SSD and DON in-serviced the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant on 02/08/16 regarding the Investigation Protocol Check List. 14) The facility Abuse and Neglect policy was updated to include that all Department Managers (Administrator, DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) were to review any investigation findings and address any concerns before finalizing an investigation. The Department Managers were in-serviced by the SSD. 15) All interviewable (BIMS score of 8 or above) residents were interviewed by the SSD and MDS Coordinator on 02/04/16 and 02/05/16. The residents were asked direct questions regarding the care they receive and any problems with facility staff. a. Resident #4 made a reportable allegation during the interviews on 02/05/16 at 3:15 PM. The resident stated a staff member man handled the resident when assisting him/her to bed. The resident was unable to determine a specific date of the incident. The resident stated the staff member urged him/her into bed, assisting the resident by holding his/her arm in a manner that made the resident feel man handled. The resident was unable to name the staff member and no staff members matched the resident's description; therefore, no staff member was suspended. i) The SSD contacted the Office of Inspector General (OIG) and Protection and Permanency (P & P) regarding the incident. ii) A skin assessment was immediately completed by the MDS Coordinator and no areas of concern were found. iii) The resident was placed on every 15-minute safety checks. iv) The Abuse and Neglect Investigation was initiated by the SSD on 02/05/16 and was completed on 02/10/16. 16) Skin assessments of non-interviewable residents (BIMS score of 8 or less) completed since 01/13/16 were reviewed by the Restorative Supervisor and the MDS Coordinator Assistant on 02/04/16. No concerns for suspicious bruising or unknown injury were determined during the review. 17) SRNA #1 was initially suspended pending the facility investigation on 01/13/16; however, the SRNA was allowed to return to work on 01/22/16. The SRNA was suspended again on 01/29/16, pending review of the investigation by the SSD. Upon completion of the review, SRNA #1 was terminated on 02/08/16. 18) SRNA #2 contacted the facility and quit on 01/29/16 without notice. 19) RN #1 was suspended on 01/29/16 and then terminated on 02/10/16. 20) The facility determined only employees who were found unsubstantiated of abuse or neglect will be allowed to return to work. The employee will be in-serviced by the SSD on the updated Abuse and Neglect policy before providing any direct care. 21) The MDS staff (MDS Coordinator and MDS Coordinator Assistant) was in-serviced on 01/29/16 by the DON regarding care planning resident behaviors. All nurses were in-serviced by the MDS Coordinator and MDS Coordinator Assistant on 02/01/16 concerning care planning resident behaviors. a. Resident #1's care plan was updated on 01/29/16 by the MDS Coordinator. b. All residents were reviewed for behaviors on 01/29/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. i) Fourteen residents' care plans were updated on 02/03/16 by the MDS Coordinator for behaviors. 22) Facility in-services including Abuse and Neglect Policy and Reviewing/Revising Care Planned Behaviors were repeated on 02/15/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. ***The State Survey Agency (SSA) validated removal of the immediate jeopardy as follows: 1) Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 who was also the facility Restorative Supervisor at 12:39 PM, the MDS Coordinator at 11:06 PM, and the MDS Coordinator Assistant at 10:39 AM revealed they were responsible for reviewing the facility's investigation dated 01/13/16 regarding Resident #1. Further interview with the team revealed they reviewed the investigation to determine the causes of the Immediate Jeopardy (IJ) and determined interventions to implement corrective action. 2) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD. Interview with the SSD on 02/11/16 at 10:48 AM revealed he was responsible to compile the facility's Abuse and Neglect Inservice for staff. Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the MDS Coordinator at 11:06 AM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were in-serviced by the SSD on 02/01/16 regarding the facility's Abuse and Neglect policy. 3) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed facility staff training was initiated on 02/01/16 and concluded on 02/04/16. Review of the facility's Abuse and Neglect posttests revealed all facility staff was given and successfully completed an in-service posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were responsible to in-service all facility staff and all in-services were completed by 02/04/16. Further interview revealed all facility staff was given a posttest covering the in-service material, and all staff completed the posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with SRNA #3 at 10:59 AM, SRNA #4 at 11:01 AM, SRNA #5 at 11:03 AM, Maintenance Staff Member #1 at 11:02 AM, and Maintenance Staff Member #2 at 11:04 AM confirmed that facility staff was in-serviced regarding the Abuse and Neglect policy and that staff was given a posttest after completing the in-service. 4) Review of the facility's Addendum of Notification Protocol roster revealed that all facility charge nurses were in-serviced by 02/09/16. Interviews conducted on 02/11/16 with the DON at 12:43 PM and the RN Supervisor at 12:20 PM revealed they in-serviced all facility charge nurses regarding the Addendum of Notification Protocol by 02/09/16. Interviews conducted on 02/11/16 with LPN #4 at 11:26 AM, RN #4 at 11:30 AM, and RN #2 at 11:38 AM confirmed they were in-serviced by the DON and RN Supervisor regarding the Addendum of Notification Protocol to include who to notify in a case of suspected abuse or injury of unknown origin. 5) Review of the in-service training and posttests for employees hired after 02/01/16 revealed they were in-serviced regarding Abuse and Neglect, Care Planning Behaviors, and Documenting Behaviors. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed all newly hired staff will be in-serviced regarding Reporting Abuse and Neglect, Care Planning, and Documenting Behaviors. Further interview confirmed all facility staff will receive bi-annual training on Abuse and Neglect. 6) Review of the Resident Rights Compliance Rounds, dated 02/04/16, 02/05/16, and 02/09/16 revealed five different residents (with a BIMS score of 8 or above) throughout the building were interviewed by the SSD weekly for concerns of abuse and neglect. Review of the Abuse and Neglect Weekly Compliance Monitoring, dated 02/01/16 and 02/08/16, revealed five different employees were interviewed by the SSD weekly to verify their comprehension and compliance with the facility's Abuse and Neglect policy. Interview with the SSD on 02/11/16 at 10:48 AM confirmed that it was his responsibility to develop and utilize the assessment tools to interview five residents and five employees weekly regarding abuse and neglect. The SSD stated he will be responsible for addressing any allegations of abuse or neglect immediately per facility policy. Interview with LPN #4 on 02/11/16 at 11:26 PM revealed she was interviewed by the SSD on 02/10/16 regarding the facility's Abuse and Neglect policy. 7) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed the RN Supervisor reviewed the 24-hour report sheets and physician's orders [REDACTED]. Interview with the RN Supervisor at 12:20 PM revealed she was responsible to review all the 24 Hour Report Sheets and physician's orders [REDACTED]. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed the RN Supervisor reviews the 24 Hour Report Sheets and physician's orders [REDACTED]. 8) Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM revealed all allegations of abuse or neglect were reviewed during the daily Department Head Meeting. 9) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed Resident Behavior Sheets were reviewed daily during the meeting. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM confirmed resident behavior sheets are reviewed daily. Further interviews on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to care plan any new resident behaviors immediately. 10) Review of the Quality Assurance (QA) meeting minutes, dated 02/08/16, revealed all non-interviewable (BIMS score less than 8) residents' skin assessments were reviewed for injuries of unknown origin. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed all non-interviewable residents' skin assessments were reviewed for injuries of unknown origin and no concerns were identified. 11) Review of the Investigation Check List revealed it included who was notified of the alleged abuse, who completed the investigation, who reviewed the information prior to closing the investigation, and a more complete history of the resident involved. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they were responsible to compile an Investigation Check List and were responsible to complete all facility investigations. Further interview with the SSD on 02/11/16 at 10:48 AM revealed he reviewed all past facility investigations since April 2015 on 02/09/16 and no concerns were identified. The SSD stated he used the Investigation Check List and the facility's Abuse and Neglect policy to review all the past investigations. 12) Review of the Abuse and Neglect Training Inservice Investigation Revision, dated 02/05/16, revealed all Department Managers were in-serviced by the SSD. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced by the SSD on 02/05/16 regarding the Investigation Check List. 13) Review of the Investigation Protocol Check List in-service roster, dated 02/08/16, revealed the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD and DON. Interviews on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they developed the Investigation Protocol Check List to assist during the beginning of any abuse or neglect investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the Investigation Protocol Check List. 14) Review of the facility's Abuse and Neglect policy revealed the policy had been updated to instruct all Department Managers to review any investigation findings and address any concerns before finalizing an investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the updated Abuse and Neglect policy. 15) Review of the statement made by the SSD, dated 02/05/16, revealed all interviewable (BIMS score of 8 or above) residents were interviewed. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to interview all capable residents and they asked direct questions regarding care and issues with the facility staff. Interviews with Resident B on 02/11/16 at 11:40 AM and Resident D at 11:45 AM revealed facility staff had asked the resident about concerns for abuse, neglect, and issues with facility staff. Review of the facility's investigation, dated 02/05/16, revealed the facility had f

Based on interview, record review, review of the facility's policy, and review of the facility's investigation it was determined the facility failed to ensure an allegation of abuse was immediately reported to the administrator, and failed to ensure residents were protected from abuse for one (1) of three (3) sampled residents (Resident #1). Interview with State Registered Nurse Aide (SRNA) #2 on 01/27/16 at 3:25 PM revealed during 3:00 AM rounds on 01/13/16, she witnessed SRNA #1 taunt and agitate Resident #1 by stating, I got your food stamp card. The resident became upset and yelled for SRNA #1 to leave his/her room. SRNA #2 stated she witnessed SRNA #1 walk up to Resident #1 and put both middle fingers in the resident's face. Although SRNA #2 viewed the incident as an abusive act, she failed to report the incident immediately. Interview with Registered Nurse (RN) #1 on 01/27/16 at 4:21 PM revealed on 01/13/16 around lunchtime (exact time unknown) Resident #1 reported that boy (SRNA#1) was going to take his/her food stamps and demonstrated how the SRNA stuck his middle fingers in his/her face. The resident stated the incident had occurred last night (on 01/13/16 during 3:00 AM rounds). The RN failed to report the allegation or start an investigation after the resident reported the alleged incident. Further interview with RN #1 revealed during the 3:00 PM shift on 01/13/16, SRNA #2 returned to work and reported the incident she had witnessed. The facility began an investigation after SRNA #2 reported the incident to RN #1. SRNA # 1 was not working at the time the incident was reported and was placed on immediate suspension after the facility investigation was initiated. The facility placed SRNA #1 on suspension on 01/13/16 pending an investigation. Review of the facility's investigation, dated 01/13/16, revealed SRNA #2 stated, I saw (SRNA #1) do this and SRNA #1 denied the allegation. Interview with the Director of Nursing (DON) on 01/27/16 at 3:40 PM revealed the facility determined the incident was a he said, she said incident, so the facility allowed SRNA #1 to return to work. According to the facility's investigation, SRNA #1 was to be placed on day shift where he would be closely monitored. However, there was no evidence the facility closely monitored SRNA #1. After one day, SRNA #1 returned to work on the night shift, unsupervised. The facility's failure to ensure staff reported witnessed incidents of abuse and allegations of abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/29/16 and determined to exist on 01/13/16 at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280). The facility was notified of the Immediate Jeopardy on 01/29/16. An acceptable Allegation of Compliance was received on 02/10/16, which alleged removal of the Immediate Jeopardy on 02/10/16. A partial extended survey was conducted on 02/11/16. The State Survey Agency determined the Immediate Jeopardy was removed on 02/10/16, which lowered the Scope and Severity to D at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of facility's policy titled Abuse Prohibition-Abuse, Neglect, and Misappropriation of Residents' Property, undated, revealed the facility upholds resident rights to be free and strictly prohibits verbal, sexual, physical, and mental abuse of residents. The policy stated residents shall not be subject to abuse by anyone and it was the policy of the facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse, misappropriation of residents' property or injury of unknown origin. The policy defined verbal abuse as any use of oral, written, or gestured language that included disparaging and derogatory terms to residents. Further review revealed any report or suspicion of an incident was to be reported immediately to the charge nurse. The policy stated residents would receive measures to ensure his/her immediate safety and well-being following the alleged incident and during the investigation process. Review of Resident #1's medical record revealed the facility readmitted the resident on 12/22/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/01/16, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 3, indicating the resident was severely cognitively impaired. Review of the resident's care plan, dated 10/04/13, revealed the resident was at risk to be socially inappropriate, with interventions that included for caregivers to provide opportunity for positive interaction and attention. Interview with SRNA #1 on 01/27/16 at 1:30 PM, SRNA #2 on 01/27/16 at 3:25 PM, RN #1 on 01/27/16 at 4:21 PM, Licensed Practical Nurse (LPN) #2 on 01/29/16 at 11:33 PM, and the Activities Director on 01/29/16 at 11:38 AM revealed Resident #1 would often (approximately monthly) become upset about not receiving his/her food stamps and Social Security check. Interviews conducted on 01/27/16 with the Director of Nursing (DON) at 3:40 PM, LPN #3 at 4:00 PM, and RN #1 at 4:21 PM revealed the resident had been sexually abused as a child and often verbalized the details of the abuse. Continued interview with LPN #3 revealed when Resident #1 was interviewed by facility staff on 01/13/16 about the incident, the resident described the act of SRNA #1 sticking his middle fingers in his/her face as being sexual. Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed during the 3:00 AM rounds on 01/13/16, she and SRNA #1 were in Resident #1's room assisting the resident. SRNA #2 stated SRNA #1 started joking with Resident #1, and then began taunting Resident #1 regarding the resident's food stamp card. SRNA #1 was witnessed to say, I got your food stamp card. Resident #1 became agitated and upset and yelled at SRNA #1 to leave his/her room. SRNA #1 was witnessed to walk up to the resident and put both middle fingers in the resident's face. Further interview with SRNA #2 revealed she did not report the incident at the time it occurred because following the incident she became busy with another resident and it slipped my mind. The SRNA reported she was aware allegations of abuse were supposed to be reported immediately; however, she failed to report the incident immediately. SRNA #2 stated she returned to work that afternoon (3:00 PM shift) of 01/13/16 and reported the allegation to RN #1. Interview with RN #1 on 01/27/16 at 4:21 PM revealed she was responsible for Resident #1's care on the day shift on 01/13/16. The RN stated around lunchtime (exact time unknown) on 01/13/16, Resident #1 began talking about that boy (SRNA #1). The resident reported to the RN that on the previous night (01/13/16) that boy said he was going to take his/her food stamps. The resident demonstrated how the SRNA had stuck his middle fingers in his/her face. The RN stated she questioned the resident in an attempt to get a description of that boy but was unable to do so. RN #1 stated that SRNA #1 was the only male SRNA working on the resident's hallway the night before. Although Resident #1 made an allegation of abuse to the RN, she failed to report the allegation or start an investigation. Further interview with RN #1 on 01/27/16 at 4:21 PM revealed SRNA #2 returned to work on 01/13/16 for the 3:00 PM shift. The RN stated SRNA #2 reported to her that she had witnessed an incident between Resident #1 and SRNA #1 during the 3:00 AM rounds on 01/13/16. The RN stated after SRNA #2 told her about the incident she knew it had to be true. The RN stated the SRNA had told her almost verbatim what Resident #1 had reported. RN #1 reported the incident to facility administration staff and began an investigation. Review of the facility's investigation, dated 01/13/16, revealed facility staff (LPN #3) interviewed Resident #1 regarding the allegation. Review of the Witness Statement Form, dated 01/13/16, revealed Resident #1 described the incident stating, He put his hands in my face and demonstrated to the LPN how SRNA #1 was sticking his middle fingers in his/her face. The resident later described the act of the SRNA sticking his middle fingers in his/her face as being sexual. When asked by the LPN if that boy had hurt the resident, the resident responded, No, just threatened me. The witness form stated the resident was unable to give any description of that boy. Interviews with unsampled Residents B and C (whom the facility assessed to be cognitively intact) conducted on 01/27/16 at 11:40 AM revealed both residents had overheard SRNA #1 yell at Resident #1 on different occasions (dates unknown). Resident B stated he/she had overheard SRNA #1 yell for Resident #1 to shut up. Resident C stated he/she had overheard SRNA #1 yell and mock Resident #1. The residents stated they were interviewed related to staff treatment of [REDACTED].#1's treatment of [REDACTED]. Interview with the DON on 01/27/16 at 3:40 PM revealed the facility viewed the incident as he said, she said and was unable to determine the incident occurred. The facility unsubstantiated the allegation and allowed SRNA #1 to return to work on 01/21/16. Review of the facility's investigation and further interview with the DON revealed SRNA #1 was placed on day shift so he could be closely monitored. Review of SRNA #1's time clock report revealed after one day of returning to work, the SRNA was placed back on night shift and worked three shifts (01/23/16, 01/24/16, and 01/25/16). The DON stated no monitoring system had been put into place for SRNA #1. Further interview with the DON revealed facility staff failed to report the allegation when it was witnessed and again when Resident #1 reported the allegation. The DON stated any suspected abuse should be reported immediately. Interview with the Administrator on 01/28/16 at 4:28 PM revealed he had not been aware SRNA #1 returned to work on night shift. The Administrator stated he had not put a system in place to monitor SRNA #1. He further stated the witnessed abuse and Resident #1's reporting the allegation should have initiated the facility's investigation immediately. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/10/16. The facility implemented the following actions to remove Immediate Jeopardy: 1) On 02/04/16, a team that included the Administrator, Director of Nursing (DON), Social Services Director (SSD), Registered Nurse (RN) Supervisor, Restorative Supervisor, Minimum Data Set (MDS) Coordinator, and MDS Coordinator Assistant reviewed the facility's investigation regarding Resident #1 to determine the cause(s) of the Immediate Jeopardy (IJ) and to implement corrective action. The team determined the causes of IJ to include: a. Not reporting the allegation in a timely manner per facility policy. b. Not completing a thorough investigation. c. The accused staff member was allowed to return to work prior to a thorough investigation being completed. d. Resident #1's care plan was not updated to include new behaviors or concerns. The team determined Resident #1 was the only resident impacted by the alleged incident; however, any facility resident could have been impacted. The facility is divided into three nursing areas: Team 1, Team 2, and Team 3. Resident #1 resided on Team 2, where the accused staff member worked. The DON completed the investigation of the initial allegation and identified the following employees as being involved: SRNA #1, SRNA #2, and RN #1. 2) An Abuse and Neglect Inservice was compiled by the SSD from federal regulations to include: a. What abuse means b. Types of Abuse c. Who is responsible for reporting allegations d. Who allegations are reported to e. Time frames to report allegations in f. Suspension of accused employee g. Disciplinary actions for failure to report according to the abuse policy h. How to protect the resident after the allegation is made The team (Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) was in-serviced on Abuse and Neglect by the SSD on 02/01/16. 3) Facility staff began in-service training on Abuse and Neglect on 02/01/16. The in-service training was given by the DON, SSD, RN Supervisor, Restorative Supervisor, and MDS Coordinator Assistant. All facility staff completed the Abuse and Neglect In-service training by 02/04/16. A posttest was completed by all staff after completing the in-service training with a 100% pass rate. 4) Facility charge nurses were in-serviced by the DON and RN Supervisor on the Addendum of Notification Protocol by 02/09/16. The in-service included who to notify in a case of suspected abuse or injury of unknown origin. 5) During the hiring process, all new staff will be in-serviced by the DON and SSD to include: a. Reporting Abuse and Neglect b. Care planning Behaviors c. Documenting Behaviors All staff will receive a bi-annual in-service training on Abuse and Neglect by the SSD. 6) To ensure a complete investigation the SSD developed an Assessment Tool to monitor compliance with resident rights and an Assessment Tool to document the resident and staff interviews. a. Five different residents throughout the building (with a Brief Interview for Mental Status score of 8 or above) will be interviewed by the SSD weekly for concerns of abuse or neglect. b. Five different employees will be interviewed by the SSD weekly to verify their comprehension and compliance with the facility Abuse and Neglect policy. Any allegations of abuse or neglect are to be addressed immediately per facility policy by the SSD. 7) Any incidents of abuse or neglect will be listed on the 24-hour report sheet. Starting 02/05/16 all 24 Hour Report Sheets and physician's orders [REDACTED]. Any issues or concerns will be reported during the daily Department Head Meeting. 8) During the daily Department Head Meetings, all allegations of abuse or neglect will be reviewed by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 9) On a daily basis, all resident behavior sheets are reviewed by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant for unusual behaviors. Any new behaviors or concerns will be care planned immediately by the MDS Coordinator and MDS Coordinator Assistant. 10) During the weekly Quality Assurance (QA) meeting all non-interviewable (Brief Interview for Mental Status score less than 8) residents' skin assessments are reviewed for injuries of unknown origin by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 11) An Investigation Check List was compiled by the DON and SSD to ensure investigations were completed according to facility policy. The checklist included: a. Who was notified of the alleged abuse. b. Who completed the investigation. c. Who reviewed the information prior to closing the investigation. A more complete history of the resident involved, to include: cognitive function, Brief Interview for Mental Status (BIMS) score, and any pertinent medical and psychiatric history. All investigations are to be completed by the SSD or the DON. All past facility investigations (since last survey in April 2015) were reviewed by the SSD on 02/09/16. The SSD used the Investigation Check List and the facility's Abuse and Neglect policy to review the investigations to ensure a thorough investigation had been completed. 12) All Department Managers were in-serviced on the Investigation Check List by the SSD or DON on 02/05/16. 13) An Investigation Protocol Check List was developed by the SSD and DON to assist during the beginning of any abuse or neglect investigation. The SSD and DON in-serviced the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant on 02/08/16 regarding the Investigation Protocol Check List. 14) The facility Abuse and Neglect policy was updated to include that all Department Managers (Administrator, DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) were to review any investigation findings and address any concerns before finalizing an investigation. The Department Managers were in-serviced by the SSD. 15) All interviewable (BIMS score of 8 or above) residents were interviewed by the SSD and MDS Coordinator on 02/04/16 and 02/05/16. The residents were asked direct questions regarding the care they receive and any problems with facility staff. a. Resident #4 made a reportable allegation during the interviews on 02/05/16 at 3:15 PM. The resident stated a staff member man handled the resident when assisting him/her to bed. The resident was unable to determine a specific date of the incident. The resident stated the staff member urged him/her into bed, assisting the resident by holding his/her arm in a manner that made the resident feel man handled. The resident was unable to name the staff member and no staff members matched the resident's description; therefore, no staff member was suspended. i) The SSD contacted the Office of Inspector General (OIG) and Protection and Permanency (P & P) regarding the incident. ii) A skin assessment was immediately completed by the MDS Coordinator and no areas of concern were found. iii) The resident was placed on every 15-minute safety checks. iv) The Abuse and Neglect Investigation was initiated by the SSD on 02/05/16 and was completed on 02/10/16. 16) Skin assessments of non-interviewable residents (BIMS score of 8 or less) completed since 01/13/16 were reviewed by the Restorative Supervisor and the MDS Coordinator Assistant on 02/04/16. No concerns for suspicious bruising or unknown injury were determined during the review. 17) SRNA #1 was initially suspended pending the facility investigation on 01/13/16; however, the SRNA was allowed to return to work on 01/22/16. The SRNA was suspended again on 01/29/16, pending review of the investigation by the SSD. Upon completion of the review, SRNA #1 was terminated on 02/08/16. 18) SRNA #2 contacted the facility and quit on 01/29/16 without notice. 19) RN #1 was suspended on 01/29/16 and then terminated on 02/10/16. 20) The facility determined only employees who were found unsubstantiated of abuse or neglect will be allowed to return to work. The employee will be in-serviced by the SSD on the updated Abuse and Neglect policy before providing any direct care. 21) The MDS staff (MDS Coordinator and MDS Coordinator Assistant) was in-serviced on 01/29/16 by the DON regarding care planning resident behaviors. All nurses were in-serviced by the MDS Coordinator and MDS Coordinator Assistant on 02/01/16 concerning care planning resident behaviors. a. Resident #1's care plan was updated on 01/29/16 by the MDS Coordinator. b. All residents were reviewed for behaviors on 01/29/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. i) Fourteen residents' care plans were updated on 02/03/16 by the MDS Coordinator for behaviors. 22) Facility in-services including Abuse and Neglect Policy and Reviewing/Revising Care Planned Behaviors were repeated on 02/15/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. ***The State Survey Agency (SSA) validated removal of the immediate jeopardy as follows: 1) Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 who was also the facility Restorative Supervisor at 12:39 PM, the MDS Coordinator at 11:06 PM, and the MDS Coordinator Assistant at 10:39 AM revealed they were responsible for reviewing the facility's investigation dated 01/13/16 regarding Resident #1. Further interview with the team revealed they reviewed the investigation to determine the causes of the Immediate Jeopardy (IJ) and determined interventions to implement corrective action. 2) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD. Interview with the SSD on 02/11/16 at 10:48 AM revealed he was responsible to compile the facility's Abuse and Neglect Inservice for staff. Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the MDS Coordinator at 11:06 AM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were in-serviced by the SSD on 02/01/16 regarding the facility's Abuse and Neglect policy. 3) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed facility staff training was initiated on 02/01/16 and concluded on 02/04/16. Review of the facility's Abuse and Neglect posttests revealed all facility staff was given and successfully completed an in-service posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were responsible to in-service all facility staff and all in-services were completed by 02/04/16. Further interview revealed all facility staff was given a posttest covering the in-service material, and all staff completed the posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with SRNA #3 at 10:59 AM, SRNA #4 at 11:01 AM, SRNA #5 at 11:03 AM, Maintenance Staff Member #1 at 11:02 AM, and Maintenance Staff Member #2 at 11:04 AM confirmed that facility staff was in-serviced regarding the Abuse and Neglect policy and that staff was given a posttest after completing the in-service. 4) Review of the facility's Addendum of Notification Protocol roster revealed that all facility charge nurses were in-serviced by 02/09/16. Interviews conducted on 02/11/16 with the DON at 12:43 PM and the RN Supervisor at 12:20 PM revealed they in-serviced all facility charge nurses regarding the Addendum of Notification Protocol by 02/09/16. Interviews conducted on 02/11/16 with LPN #4 at 11:26 AM, RN #4 at 11:30 AM, and RN #2 at 11:38 AM confirmed they were in-serviced by the DON and RN Supervisor regarding the Addendum of Notification Protocol to include who to notify in a case of suspected abuse or injury of unknown origin. 5) Review of the in-service training and posttests for employees hired after 02/01/16 revealed they were in-serviced regarding Abuse and Neglect, Care Planning Behaviors, and Documenting Behaviors. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed all newly hired staff will be in-serviced regarding Reporting Abuse and Neglect, Care Planning, and Documenting Behaviors. Further interview confirmed all facility staff will receive bi-annual training on Abuse and Neglect. 6) Review of the Resident Rights Compliance Rounds, dated 02/04/16, 02/05/16, and 02/09/16 revealed five different residents (with a BIMS score of 8 or above) throughout the building were interviewed by the SSD weekly for concerns of abuse and neglect. Review of the Abuse and Neglect Weekly Compliance Monitoring, dated 02/01/16 and 02/08/16, revealed five different employees were interviewed by the SSD weekly to verify their comprehension and compliance with the facility's Abuse and Neglect policy. Interview with the SSD on 02/11/16 at 10:48 AM confirmed that it was his responsibility to develop and utilize the assessment tools to interview five residents and five employees weekly regarding abuse and neglect. The SSD stated he will be responsible for addressing any allegations of abuse or neglect immediately per facility policy. Interview with LPN #4 on 02/11/16 at 11:26 PM revealed she was interviewed by the SSD on 02/10/16 regarding the facility's Abuse and Neglect policy. 7) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed the RN Supervisor reviewed the 24-hour report sheets and physician's orders [REDACTED]. Interview with the RN Supervisor at 12:20 PM revealed she was responsible to review all the 24 Hour Report Sheets and physician's orders [REDACTED]. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed the RN Supervisor reviews the 24 Hour Report Sheets and physician's orders [REDACTED]. 8) Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM revealed all allegations of abuse or neglect were reviewed during the daily Department Head Meeting. 9) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed Resident Behavior Sheets were reviewed daily during the meeting. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM confirmed resident behavior sheets are reviewed daily. Further interviews on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to care plan any new resident behaviors immediately. 10) Review of the Quality Assurance (QA) meeting minutes, dated 02/08/16, revealed all non-interviewable (BIMS score less than 8) residents' skin assessments were reviewed for injuries of unknown origin. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed all non-interviewable residents' skin assessments were reviewed for injuries of unknown origin and no concerns were identified. 11) Review of the Investigation Check List revealed it included who was notified of the alleged abuse, who completed the investigation, who reviewed the information prior to closing the investigation, and a more complete history of the resident involved. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they were responsible to compile an Investigation Check List and were responsible to complete all facility investigations. Further interview with the SSD on 02/11/16 at 10:48 AM revealed he reviewed all past facility investigations since April 2015 on 02/09/16 and no concerns were identified. The SSD stated he used the Investigation Check List and the facility's Abuse and Neglect policy to review all the past investigations. 12) Review of the Abuse and Neglect Training Inservice Investigation Revision, dated 02/05/16, revealed all Department Managers were in-serviced by the SSD. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced by the SSD on 02/05/16 regarding the Investigation Check List. 13) Review of the Investigation Protocol Check List in-service roster, dated 02/08/16, revealed the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD and DON. Interviews on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they developed the Investigation Protocol Check List to assist during the beginning of any abuse or neglect investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the Investigation Protocol Check List. 14) Review of the facility's Abuse and Neglect policy revealed the policy had been updated to instruct all Department Managers to review any investigation findings and address any concerns before finalizing an investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the updated Abuse and Neglect policy. 15) Review of the statement made by the SSD, dated 02/05/16, revealed all interviewable (BIMS score of 8 or above) residents were interviewed. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to interview all capable residents and they asked direct questions regarding care and issues with the facility staff. Interviews with Resident B on 02/11/16 at 11:40 AM and Resident D at 11:45 AM revealed facility staff had asked the resident about concerns for abuse, neglect, and issues with facility staff. Review of the facility's investigation, dated 02/05/16, revealed the facility had followed policy to complete a thorough investigation. Review of Resident #4's safety check sheets, revealed the facility placed Resident #4 on 15-minute safety checks after the allegation was made on 02/05/16 and continued until present (02/11/16). Interview with the SSD on 02/11/16 revealed the investigation was initiated on 02/05/16 and finalized on 02/10/16 after the findings were reviewed during the Department Head Meeting. 16) Review of the statement made by the Restorative Supervisor and the MDS Coordinator Assistant, dated 02/04/16, revealed all non-interviewable (BIMS scores of 8 or below) residents' skin assessments completed since 01/13/16 were reviewed. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 PM and LPN #3 (Restorative Supervisor) at 12:39 PM revealed they reviewed all of the non-interviewable skin assessments and no concerns were identified. 17) Review of statements made by the DON and RN Supervisor, dated 01/29/16, revealed SRNA #1 was suspended on 01/29/16, and then later terminated on 02/08/16. Interviews with the RN Supervisor on 02/11/16 at 12:20 PM and the DON at 12:43 PM confirmed SRNA #1 was suspended and then later terminated on 02/08/16. 18) Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed she quit the facility without notice. 19) Review of the statements made by the DON and RN Supervisor revealed RN #1 was suspended on 01/29/16 and terminated on 02/10/16. Interviews on 02/11/16 with the RN Supervisor at 12:20 PM and the DON at 12:43 PM revealed RN #1 was suspended and later terminated. 20) Interview with the SSD on 02/11/16 at 10:48 AM revealed any employee that was named in an allegation of abuse or neglect that was allowed to return to work will be in-serviced on the updated Abuse and Neglect policy prior to providing any direct care. 21) Revie

Based on interview, record review, review of the facility's Abuse Prohibition policy, and review of the facility's investigation, it was determined the facility failed to ensure staff implemented written procedures to prohibit mistreatment, neglect, and abuse per the facility's policy for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure an allegation of abuse involving Resident #1 was reported timely and per the facility's policy. In addition, the facility failed to ensure that during its investigation, resident specific interviews were conducted prior to allowing the alleged perpetrator to provide direct resident care. Interview with State Registered Nurse Aide (SRNA) #2 on 01/27/16 at 3:25 PM revealed during 3:00 AM rounds on 01/13/16 she witnessed SRNA #1 taunt and agitate Resident #1 by stating, I got your food stamp card. After the resident became upset and yelled for SRNA #1 to leave his/her room, SRNA #1 walked up to the resident and put both of his middle fingers in the resident's face. Although SRNA #2 viewed the incident as abuse and was aware to report abuse immediately, the SRNA failed to report the allegation until after returning to work that afternoon. SRNA #1 was allowed to complete his shift providing direct care. Interview with Registered Nurse (RN) #1 on 01/27/16 at 4:21 PM revealed during lunchtime (exact time unknown) on 01/13/16 Resident #1 described an incident with that boy to the nurse. The resident stated that boy said he was going to take his/her food stamps and demonstrated to the nurse sticking both middle fingers in his/her face. Further interview revealed the RN did not report the allegation at the time, nor did she initiate an investigation. RN #1 stated SRNA #2 returned to work on the afternoon of 01/13/16 (3:00 PM shift) and reported the incident to her. The facility began an investigation and SRNA #1 was placed on suspension pending the investigation. Interview with the Director of Nursing (DON) on 01/27/16 at 3:40 PM revealed the facility was unable to determine the incident occurred, calling it a he said, she said event. The DON stated SRNA #1 was allowed to come back to work on day shift so he could be closely monitored. Review of the SRNA's time clock report revealed after one day he returned to night shift. The DON stated the facility had no system in place to monitor the SRNA to ensure resident safety. The facility's failure to implement its policy and procedures related to reporting and investigating has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/29/16 and determined to exist on 01/13/16 at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280). The facility was notified of the Immediate Jeopardy on 01/29/16. An acceptable Allegation of Compliance was received on 02/10/16, which alleged removal of the Immediate Jeopardy on 02/10/16. A partial extended survey was conducted on 02/11/16. The State Survey Agency determined the Immediate Jeopardy was removed on 02/10/16, which lowered the Scope and Severity to D at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Abuse Prohibition-Abuse, Neglect, and Misappropriation of Residents' Property, date unknown, revealed the facility upholds resident rights to be free and strictly prohibits verbal, sexual, physical, and mental abuse of residents. The policy states residents shall not be subject to abuse by anyone and it is the policy of the facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse, misappropriation of residents' property, or injury of unknown origin. The policy defines verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents. According to the policy, any report or suspicion of an incident is to be reported immediately to the charge nurse. Further review revealed it is the Administrator's ultimate responsibility to assure that all alleged abuses are reported, investigated immediately, and policy and procedures are followed. Review of Resident #1's medical record revealed the facility last admitted the resident on 12/22/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/01/16, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 3, indicating the resident to be severely cognitively impaired. Review of the resident's care plan, dated 10/04/13, revealed the resident was at risk to be socially inappropriate, with interventions which included for caregivers to provide opportunity for positive interaction and attention. Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed she and SRNA #1 were responsible for Resident #1's care on 01/12/16 going into the morning of 01/13/16. SRNA #2 stated she witnessed SRNA #1 joke and taunt Resident #1 by stating, I got your food stamp card. The SRNA stated Resident #1 often becomes upset about not receiving a monthly food stamp card and this would be a known behavioral trigger for the resident. The SRNA stated Resident #1 became upset with SRNA #1 and yelled at him to leave his/her room. SRNA #2 stated she witnessed SRNA #1 walk up to the resident and put both of his middle fingers in the resident's face. Further interview revealed the SRNA did not report the incident at the time it occurred, stating she became busy with another resident after the incident happened and it slipped her mind. The SRNA acknowledged she was aware that facility policy instructed staff to report any witness of abuse immediately; however, she failed to report the incident. Interview with RN #1 on 01/27/16 at 4:21 PM revealed on 01/13/16 during lunchtime (exact time unknown) Resident #1 reported an allegation of abuse to her. According to RN #1, Resident #1 reported to her that boy said he was going to take his/her food stamps away and demonstrated to the RN sticking both middle fingers up in his/her face. The RN stated she questioned the resident in an attempt to gain a description of that boy but the resident was unable to do so. However, there was only one male working on the resident's hall that morning. The RN acknowledged the resident made an allegation of abuse, and per facility policy all allegations of abuse should be reported immediately; however, the RN failed to report the allegation. Further interview with the RN revealed SRNA #2 reported to work on the afternoon of 01/13/16 (3:00 PM shift). The RN stated SRNA #2 reported she witnessed SRNA #1 put his middle fingers in Resident #1's face and taunt the resident by saying, I have your food stamps. The RN reported the allegation to facility administrative staff at that time. Interviews with unsampled Residents B and C (whom the facility assessed to be cognitively intact) conducted on 01/27/16 at 11:40 AM, revealed both residents had overheard SRNA #1 (alleged perpetrator) yell at Resident #1 on different occasions (dates unknown). Resident B stated he/she had overheard SRNA #1 yell for Resident #1 to shut up. Resident C stated he/she had overheard SRNA #1 yell and mock Resident #1. The residents stated that the facility interviewed them about staff treatment; however, they did not ask questions regarding SRNA #1's treatment of [REDACTED]. Review of the facility's investigation revealed SRNA #1 was not working at the time the investigation was initiated and was placed on suspension pending the results of the investigation. The investigation stated, None of the staff have ever witnessed an inappropriate behavior from (SRNA #1); however, the investigation also noted that SRNA #2 stated that she saw SRNA taunt the resident and put his middle fingers in the resident's face. The investigation further stated that the resident was unable to give a description of the person and unable to recall the incident, even though Resident #1 initially reported the incident and gave the same account when the resident was initially interviewed by staff. The facility failed to consider Resident #1's initial report of the incident, Resident #1's initial interview, and failed to identify concerns from other residents' interviews that lived on the same hallway as Resident #1 when they determined the allegation was a he said, she said incident. The facility's investigation stated 30 residents were interviewed regarding SRNA #1, including Resident B and Resident C. Interviews conducted on 02/11/16 with the RN Supervisor at 12:20 PM and LPN #3 at 12:39 PM revealed they conducted the resident interviews; however, they did not ask specific questions regarding care provided by or concerns with SRNA #1. The investigation stated SRNA #1 was placed on day shift where he would be closely monitored. Review of SRNA #1's time clock record revealed the SRNA returned to work on 01/21/16 on day shift. However, further review of time clock records revealed SRNA #1 worked on 01/23/16, 01/24/16, and 01/25/16 during night shift, unsupervised. Interview with the DON on 01/29/16 at 11:45 AM revealed the facility failed to follow their own policy to ensure allegations of abuse were reported and investigated immediately. According to the DON, when the incident was witnessed it should have been reported to Administrative staff as well as after Resident #1 reported the allegation to staff on 01/13/16 during lunch. Although the facility's investigation revealed Resident #1 reported the allegation on two occasions and the incident was witnessed by facility staff, the facility failed to substantiate the allegation and allowed SRNA #1 to return to work. The facility failed to implement its policy to ensure Resident #1 and other residents were protected from potential abuse. Interview with the Administrator on 01/28/16 at 4:28 PM revealed facility staff should have followed the facility Abuse policy to ensure allegations were reported immediately. The Administrator stated SRNA #2 should have reported the incident when it occurred and RN #1 should have reported the allegation when told by Resident #1 it had occurred. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/10/16. The facility implemented the following actions to remove Immediate Jeopardy: 1) On 02/04/16, a team that included the Administrator, Director of Nursing (DON), Social Services Director (SSD), Registered Nurse (RN) Supervisor, Restorative Supervisor, Minimum Data Set (MDS) Coordinator, and MDS Coordinator Assistant reviewed the facility's investigation regarding Resident #1 to determine the cause(s) of the Immediate Jeopardy (IJ) and to implement corrective action. The team determined the causes of IJ to include: a. Not reporting the allegation in a timely manner per facility policy. b. Not completing a thorough investigation. c. The accused staff member was allowed to return to work prior to a thorough investigation being completed. d. Resident #1's care plan was not updated to include new behaviors or concerns. The team determined Resident #1 was the only resident impacted by the alleged incident; however, any facility resident could have been impacted. The facility is divided into three nursing areas: Team 1, Team 2, and Team 3. Resident #1 resided on Team 2, where the accused staff member worked. The DON completed the investigation of the initial allegation and identified the following employees as being involved: SRNA #1, SRNA #2, and RN #1. 2) An Abuse and Neglect Inservice was compiled by the SSD from federal regulations to include: a. What abuse means b. Types of Abuse c. Who is responsible for reporting allegations d. Who allegations are reported to e. Time frames to report allegations in f. Suspension of accused employee g. Disciplinary actions for failure to report according to the abuse policy h. How to protect the resident after the allegation is made The team (Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) was in-serviced on Abuse and Neglect by the SSD on 02/01/16. 3) Facility staff began in-service training on Abuse and Neglect on 02/01/16. The in-service training was given by the DON, SSD, RN Supervisor, Restorative Supervisor, and MDS Coordinator Assistant. All facility staff completed the Abuse and Neglect In-service training by 02/04/16. A posttest was completed by all staff after completing the in-service training with a 100% pass rate. 4) Facility charge nurses were in-serviced by the DON and RN Supervisor on the Addendum of Notification Protocol by 02/09/16. The in-service included who to notify in a case of suspected abuse or injury of unknown origin. 5) During the hiring process, all new staff will be in-serviced by the DON and SSD to include: a. Reporting Abuse and Neglect b. Care planning Behaviors c. Documenting Behaviors All staff will receive a bi-annual in-service training on Abuse and Neglect by the SSD. 6) To ensure a complete investigation the SSD developed an Assessment Tool to monitor compliance with resident rights and an Assessment Tool to document the resident and staff interviews. a. Five different residents throughout the building (with a Brief Interview for Mental Status score of 8 or above) will be interviewed by the SSD weekly for concerns of abuse or neglect. b. Five different employees will be interviewed by the SSD weekly to verify their comprehension and compliance with the facility Abuse and Neglect policy. Any allegations of abuse or neglect are to be addressed immediately per facility policy by the SSD. 7) Any incidents of abuse or neglect will be listed on the 24-hour report sheet. Starting 02/05/16 all 24 Hour Report Sheets and physician's orders [REDACTED]. Any issues or concerns will be reported during the daily Department Head Meeting. 8) During the daily Department Head Meetings, all allegations of abuse or neglect will be reviewed by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 9) On a daily basis, all resident behavior sheets are reviewed by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant for unusual behaviors. Any new behaviors or concerns will be care planned immediately by the MDS Coordinator and MDS Coordinator Assistant. 10) During the weekly Quality Assurance (QA) meeting all non-interviewable (Brief Interview for Mental Status score less than 8) residents' skin assessments are reviewed for injuries of unknown origin by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 11) An Investigation Check List was compiled by the DON and SSD to ensure investigations were completed according to facility policy. The checklist included: a. Who was notified of the alleged abuse. b. Who completed the investigation. c. Who reviewed the information prior to closing the investigation. A more complete history of the resident involved, to include: cognitive function, Brief Interview for Mental Status (BIMS) score, and any pertinent medical and psychiatric history. All investigations are to be completed by the SSD or the DON. All past facility investigations (since last survey in April 2015) were reviewed by the SSD on 02/09/16. The SSD used the Investigation Check List and the facility's Abuse and Neglect policy to review the investigations to ensure a thorough investigation had been completed. 12) All Department Managers were in-serviced on the Investigation Check List by the SSD or DON on 02/05/16. 13) An Investigation Protocol Check List was developed by the SSD and DON to assist during the beginning of any abuse or neglect investigation. The SSD and DON in-serviced the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant on 02/08/16 regarding the Investigation Protocol Check List. 14) The facility Abuse and Neglect policy was updated to include that all Department Managers (Administrator, DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) were to review any investigation findings and address any concerns before finalizing an investigation. The Department Managers were in-serviced by the SSD. 15) All interviewable (BIMS score of 8 or above) residents were interviewed by the SSD and MDS Coordinator on 02/04/16 and 02/05/16. The residents were asked direct questions regarding the care they receive and any problems with facility staff. a. Resident #4 made a reportable allegation during the interviews on 02/05/16 at 3:15 PM. The resident stated a staff member man handled the resident when assisting him/her to bed. The resident was unable to determine a specific date of the incident. The resident stated the staff member urged him/her into bed, assisting the resident by holding his/her arm in a manner that made the resident feel man handled. The resident was unable to name the staff member and no staff members matched the resident's description; therefore, no staff member was suspended. i) The SSD contacted the Office of Inspector General (OIG) and Protection and Permanency (P & P) regarding the incident. ii) A skin assessment was immediately completed by the MDS Coordinator and no areas of concern were found. iii) The resident was placed on every 15-minute safety checks. iv) The Abuse and Neglect Investigation was initiated by the SSD on 02/05/16 and was completed on 02/10/16. 16) Skin assessments of non-interviewable residents (BIMS score of 8 or less) completed since 01/13/16 were reviewed by the Restorative Supervisor and the MDS Coordinator Assistant on 02/04/16. No concerns for suspicious bruising or unknown injury were determined during the review. 17) SRNA #1 was initially suspended pending the facility investigation on 01/13/16; however, the SRNA was allowed to return to work on 01/22/16. The SRNA was suspended again on 01/29/16, pending review of the investigation by the SSD. Upon completion of the review, SRNA #1 was terminated on 02/08/16. 18) SRNA #2 contacted the facility and quit on 01/29/16 without notice. 19) RN #1 was suspended on 01/29/16 and then terminated on 02/10/16. 20) The facility determined only employees who were found unsubstantiated of abuse or neglect will be allowed to return to work. The employee will be in-serviced by the SSD on the updated Abuse and Neglect policy before providing any direct care. 21) The MDS staff (MDS Coordinator and MDS Coordinator Assistant) was in-serviced on 01/29/16 by the DON regarding care planning resident behaviors. All nurses were in-serviced by the MDS Coordinator and MDS Coordinator Assistant on 02/01/16 concerning care planning resident behaviors. a. Resident #1's care plan was updated on 01/29/16 by the MDS Coordinator. b. All residents were reviewed for behaviors on 01/29/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. i) Fourteen residents' care plans were updated on 02/03/16 by the MDS Coordinator for behaviors. 22) Facility in-services including Abuse and Neglect Policy and Reviewing/Revising Care Planned Behaviors were repeated on 02/15/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. ***The State Survey Agency (SSA) validated removal of the immediate jeopardy as follows: 1) Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 who was also the facility Restorative Supervisor at 12:39 PM, the MDS Coordinator at 11:06 PM, and the MDS Coordinator Assistant at 10:39 AM revealed they were responsible for reviewing the facility's investigation dated 01/13/16 regarding Resident #1. Further interview with the team revealed they reviewed the investigation to determine the causes of the Immediate Jeopardy (IJ) and determined interventions to implement corrective action. 2) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD. Interview with the SSD on 02/11/16 at 10:48 AM revealed he was responsible to compile the facility's Abuse and Neglect Inservice for staff. Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the MDS Coordinator at 11:06 AM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were in-serviced by the SSD on 02/01/16 regarding the facility's Abuse and Neglect policy. 3) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed facility staff training was initiated on 02/01/16 and concluded on 02/04/16. Review of the facility's Abuse and Neglect posttests revealed all facility staff was given and successfully completed an in-service posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were responsible to in-service all facility staff and all in-services were completed by 02/04/16. Further interview revealed all facility staff was given a posttest covering the in-service material, and all staff completed the posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with SRNA #3 at 10:59 AM, SRNA #4 at 11:01 AM, SRNA #5 at 11:03 AM, Maintenance Staff Member #1 at 11:02 AM, and Maintenance Staff Member #2 at 11:04 AM confirmed that facility staff was in-serviced regarding the Abuse and Neglect policy and that staff was given a posttest after completing the in-service. 4) Review of the facility's Addendum of Notification Protocol roster revealed that all facility charge nurses were in-serviced by 02/09/16. Interviews conducted on 02/11/16 with the DON at 12:43 PM and the RN Supervisor at 12:20 PM revealed they in-serviced all facility charge nurses regarding the Addendum of Notification Protocol by 02/09/16. Interviews conducted on 02/11/16 with LPN #4 at 11:26 AM, RN #4 at 11:30 AM, and RN #2 at 11:38 AM confirmed they were in-serviced by the DON and RN Supervisor regarding the Addendum of Notification Protocol to include who to notify in a case of suspected abuse or injury of unknown origin. 5) Review of the in-service training and posttests for employees hired after 02/01/16 revealed they were in-serviced regarding Abuse and Neglect, Care Planning Behaviors, and Documenting Behaviors. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed all newly hired staff will be in-serviced regarding Reporting Abuse and Neglect, Care Planning, and Documenting Behaviors. Further interview confirmed all facility staff will receive bi-annual training on Abuse and Neglect. 6) Review of the Resident Rights Compliance Rounds, dated 02/04/16, 02/05/16, and 02/09/16 revealed five different residents (with a BIMS score of 8 or above) throughout the building were interviewed by the SSD weekly for concerns of abuse and neglect. Review of the Abuse and Neglect Weekly Compliance Monitoring, dated 02/01/16 and 02/08/16, revealed five different employees were interviewed by the SSD weekly to verify their comprehension and compliance with the facility's Abuse and Neglect policy. Interview with the SSD on 02/11/16 at 10:48 AM confirmed that it was his responsibility to develop and utilize the assessment tools to interview five residents and five employees weekly regarding abuse and neglect. The SSD stated he will be responsible for addressing any allegations of abuse or neglect immediately per facility policy. Interview with LPN #4 on 02/11/16 at 11:26 PM revealed she was interviewed by the SSD on 02/10/16 regarding the facility's Abuse and Neglect policy. 7) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed the RN Supervisor reviewed the 24-hour report sheets and physician's orders [REDACTED]. Interview with the RN Supervisor at 12:20 PM revealed she was responsible to review all the 24 Hour Report Sheets and physician's orders [REDACTED]. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed the RN Supervisor reviews the 24 Hour Report Sheets and physician's orders [REDACTED]. 8) Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM revealed all allegations of abuse or neglect were reviewed during the daily Department Head Meeting. 9) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed Resident Behavior Sheets were reviewed daily during the meeting. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM confirmed resident behavior sheets are reviewed daily. Further interviews on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to care plan any new resident behaviors immediately. 10) Review of the Quality Assurance (QA) meeting minutes, dated 02/08/16, revealed all non-interviewable (BIMS score less than 8) residents' skin assessments were reviewed for injuries of unknown origin. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed all non-interviewable residents' skin assessments were reviewed for injuries of unknown origin and no concerns were identified. 11) Review of the Investigation Check List revealed it included who was notified of the alleged abuse, who completed the investigation, who reviewed the information prior to closing the investigation, and a more complete history of the resident involved. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they were responsible to compile an Investigation Check List and were responsible to complete all facility investigations. Further interview with the SSD on 02/11/16 at 10:48 AM revealed he reviewed all past facility investigations since April 2015 on 02/09/16 and no concerns were identified. The SSD stated he used the Investigation Check List and the facility's Abuse and Neglect policy to review all the past investigations. 12) Review of the Abuse and Neglect Training Inservice Investigation Revision, dated 02/05/16, revealed all Department Managers were in-serviced by the SSD. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced by the SSD on 02/05/16 regarding the Investigation Check List. 13) Review of the Investigation Protocol Check List in-service roster, dated 02/08/16, revealed the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD and DON. Interviews on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they developed the Investigation Protocol Check List to assist during the beginning of any abuse or neglect investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the Investigation Protocol Check List. 14) Review of the facility's Abuse and Neglect policy revealed the policy had been updated to instruct all Department Managers to review any investigation findings and address any concerns before finalizing an investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the updated Abuse and Neglect policy. 15) Review of the statement made by the SSD, dated 02/05/16, revealed all interviewable (BIMS score of 8 or above) residents were interviewed. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to interview all capable residents and they asked direct questions regarding care and issues with the facility staff. Interviews with Resident B on 02/11/16 at 11:40 AM and Resident D at 11:45 AM revealed facility staff had asked the resident about concerns for abuse, neglect, and issues with facility staff. Review of the facility's investigation, dated 02/05/16, revealed the facility had followed policy to complete a thorough investigation. Review of Resident #4's safety check sheets, revealed the facility placed Resident #4 on 15-minute safety checks after the allegation was made on 02/05/16 and continued until present (02/11/16). Interview with the SSD on 02/11/16 revealed the investigation was initiated on 02/05/16 and finalized on 02/10/16 after the findings were reviewed during the Department Head Meeting. 16) Review of the statement made by the Restorative Supervisor and the MDS Coordinator Assistant, dated 02/04/16, revealed all non-interviewable (BIMS scores of 8 or below) residents' skin assessments completed since 01/13/16 were reviewed. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 PM and LPN #3 (Restorative Supervisor) at 12:39 PM revealed they reviewed all of the non-interviewable skin assessments and no concerns were identified. 17) Review of statements made by the DON and RN Supervisor, dated 01/29/16, revealed SRNA #1 was suspended on 01/29/16, and then later terminated on 02/08/16. Interviews with the RN Supervisor on 02/11/16 at 12:20 PM and the DON at 12:43 PM confirmed SRNA #1 was suspended and then later terminated on 02/08/16. 18) Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed she quit the facility without notice. 19) Review of the statements made by the DON and RN Supervisor revealed RN #1 was suspended on 01/29/16 and terminated on 02/10/16. Interviews on 02/11/16 with the RN Supervisor at 12:20 PM and the DON at 12:43 PM revealed RN #1 was suspended and later terminated. 20) Interview with the SSD on 02/11/16 at 10:48 AM revealed any employee that was named in an allegation of abuse or neglect that was allowed to return to work will be in-serviced on the updated Abuse and Neglect policy prior to providing any direct care. 21) Review of the New Behavior Care Planning Policy in-service roster, dated 01/29/16, revealed the MDS Coordinator and MD

Based on interview, record review, review of the facility's policy, and review of the facility's investigation it was determined the facility failed to review and revise the care plan for one (1) of three (3) sampled residents (Resident #1) to ensure interventions were put into place regarding the resident's behaviors. Interviews with staff revealed Resident #1 often became upset and worried about not receiving his/her food stamps and Social Security check. Interviews with the Director of Nursing (DON), LPN #3, and RN #1 revealed the resident had been sexually abused as a child and often verbalized the details of the abuse. Interview with SRNA #2 revealed during rounds on 01/13/16, she witnessed SRNA #1 taunt and agitate Resident #1 by saying, I got your food stamp card, causing the resident to become upset and yell for SRNA #1 to get out of his/her room. SRNA #1 walked up to the resident and stuck both middle fingers in the resident's face. Review of the resident's care plan revealed the facility failed to address the resident's known behaviors and implement interventions that provided staff with ways to appropriately respond to the resident and help alleviate the resident's anxiety. The facility's failure to review and revise Resident #1's care plan and ensure interventions to address the resident's behaviors were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/29/16 and determined to exist on 01/13/16 at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280). The facility was notified of the Immediate Jeopardy on 01/29/16. An acceptable Allegation of Compliance was received on 02/10/16, which alleged removal of the Immediate Jeopardy on 02/10/16. A partial extended survey was conducted on 02/11/16. The State Survey Agency determined the Immediate Jeopardy was removed on 02/10/16, which lowered the Scope and Severity to D at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.20 Resident Assessment (F280) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Patient Care Plans, date unknown, revealed resident care plans should include approaches to nursing care needed, how it can best be accomplished for each patient, patient preferences, methods and approaches which are most successful, and modifications necessary to insure best results. The policy stated care plans should be reviewed, evaluated, and updated as necessary, but not less than quarterly. Review of Resident #1's medical record revealed the facility admitted the resident on 12/22/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/01/16, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 3, indicating the resident to be severely cognitively impaired. Review of the resident's care plan, dated 10/04/13, with a target date of 03/24/16 (no revision date considered ongoing) revealed the resident was at risk to be socially inappropriate, with interventions which included assisting the resident to develop more appropriate methods of coping and interacting; for caregivers to provide opportunity for positive interaction and attention; and minimizing potential for the resident's disruptive behaviors. Further review of the record revealed a readmission care plan, dated 12/25/15, that stated the resident was at risk for behavioral symptoms, with interventions to include for staff to keep the environment calm and relaxed. Interviews with State Registered Nurse Aide (SRNA) #1 on 01/27/16 at 1:30 PM, SRNA #2 on 01/27/16 at 3:25 PM, Registered Nurse (RN) #1 on 01/27/16 at 4:21 PM, Licensed Practical Nurse (LPN) #2 on 01/29/16 at 11:33 AM, and the facility Activity Director on 01/29/16 at 11:38 AM revealed Resident #1 often became upset and worried, at least monthly, about not receiving his/her food stamps and Social Security check. Further interview with the Activity Director revealed the resident often required redirection and staff had to explain to the resident that his/her money was available from facility resident funds and that the facility now provided his/her food. Interviews conducted on 01/27/16 with the Director of Nursing (DON) at 3:40 PM, LPN #3 at 4:00 PM, and RN #1 at 4:21 PM revealed the resident had been sexually abused as a child and often verbalized the details of the abuse. Review of Resident #1's care plan, dated 10/04/13, with a target date of 03/24/16 (no revision date considered ongoing) revealed the facility failed to address the resident's known history of sexual abuse and concerns regarding his/her food stamps and Social Security check. The facility failed to implement interventions that would provide staff direction on how to address the resident's concerns and behavioral triggers to avoid. Review of the facility's investigation, dated 01/13/16 (time not documented), revealed LPN #3 interviewed Resident #1 regarding the incident. The Witness Statement Form, dated 01/13/16, stated when Resident #1 was asked to tell LPN #3 about that boy the resident responded saying, he put his hands in my face and demonstrated how the SRNA had stuck his middle fingers in his/her face. The resident then described the incident as a sexual act. LPN #3 asked the resident if that boy had ever hurt the resident, and the resident stated, No, just threatened me. Interview with the MDS Coordinator Assistant on 01/29/16 at 11:01 AM revealed she and the MDS Coordinator were responsible to review and revise resident care plans. The MDS Coordinator Assistant stated residents and direct care staff were interviewed about behaviors as part of the MDS assessment. The MDS Coordinator Assistant denied being aware of Resident #1's concern regarding his/her food stamps, stating Resident #1 nor facility staff had made her aware. The MDS Coordinator Assistant stated that had they known of the resident's behaviors/concerns they would have been care planned. Further interview on 02/11/16 at 10:39 AM revealed she was aware that Resident #1 became upset and fearful about things missing from his/her room. The MDS Coordinator Assistant also stated that she was aware the resident had a history of [REDACTED]. Although the MDS Coordinator Assistant was aware of these behaviors, the Assistant stated the issues were not addressed on the resident's care plan prior to the incident. Interview with the MDS Coordinator on 02/11/16 at 11:06 AM revealed she had not been made aware by facility staff that Resident #1 became anxious or upset regarding his/her food stamps or Social Security check. She also stated she had no prior knowledge that the resident had a past history of sexual abuse. The MDS Coordinator stated that those concerns should have been on the resident's care plan prior to the incident. Interview with the Director of Nursing (DON) on 01/29/16 at 11:45 AM revealed Resident #1 had mentioned his/her food stamps to him so he would reassure the resident. He was unable to determine how often the resident mentioned his/her food stamps. The DON stated the resident's care plans should include interventions addressing the resident's behaviors. He stated the care plan should be reviewed/revised at least quarterly or with new issues, and it should be followed by facility staff. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/10/16. The facility implemented the following actions to remove Immediate Jeopardy: 1) On 02/04/16, a team that included the Administrator, Director of Nursing (DON), Social Services Director (SSD), Registered Nurse (RN) Supervisor, Restorative Supervisor, Minimum Data Set (MDS) Coordinator, and MDS Coordinator Assistant reviewed the facility's investigation regarding Resident #1 to determine the cause(s) of the Immediate Jeopardy (IJ) and to implement corrective action. The team determined the causes of IJ to include: a. Not reporting the allegation in a timely manner per facility policy. b. Not completing a thorough investigation. c. The accused staff member was allowed to return to work prior to a thorough investigation being completed. d. Resident #1's care plan was not updated to include new behaviors or concerns. The team determined Resident #1 was the only resident impacted by the alleged incident; however, any facility resident could have been impacted. The facility is divided into three nursing areas: Team 1, Team 2, and Team 3. Resident #1 resided on Team 2, where the accused staff member worked. The DON completed the investigation of the initial allegation and identified the following employees as being involved: SRNA #1, SRNA #2, and RN #1. 2) An Abuse and Neglect Inservice was compiled by the SSD from federal regulations to include: a. What abuse means b. Types of Abuse c. Who is responsible for reporting allegations d. Who allegations are reported to e. Time frames to report allegations in f. Suspension of accused employee g. Disciplinary actions for failure to report according to the abuse policy h. How to protect the resident after the allegation is made The team (Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) was in-serviced on Abuse and Neglect by the SSD on 02/01/16. 3) Facility staff began in-service training on Abuse and Neglect on 02/01/16. The in-service training was given by the DON, SSD, RN Supervisor, Restorative Supervisor, and MDS Coordinator Assistant. All facility staff completed the Abuse and Neglect In-service training by 02/04/16. A posttest was completed by all staff after completing the in-service training with a 100% pass rate. 4) Facility charge nurses were in-serviced by the DON and RN Supervisor on the Addendum of Notification Protocol by 02/09/16. The in-service included who to notify in a case of suspected abuse or injury of unknown origin. 5) During the hiring process, all new staff will be in-serviced by the DON and SSD to include: a. Reporting Abuse and Neglect b. Care planning Behaviors c. Documenting Behaviors All staff will receive a bi-annual in-service training on Abuse and Neglect by the SSD. 6) To ensure a complete investigation the SSD developed an Assessment Tool to monitor compliance with resident rights and an Assessment Tool to document the resident and staff interviews. a. Five different residents throughout the building (with a Brief Interview for Mental Status score of 8 or above) will be interviewed by the SSD weekly for concerns of abuse or neglect. b. Five different employees will be interviewed by the SSD weekly to verify their comprehension and compliance with the facility Abuse and Neglect policy. Any allegations of abuse or neglect are to be addressed immediately per facility policy by the SSD. 7) Any incidents of abuse or neglect will be listed on the 24-hour report sheet. Starting 02/05/16 all 24 Hour Report Sheets and physician's orders [REDACTED]. Any issues or concerns will be reported during the daily Department Head Meeting. 8) During the daily Department Head Meetings, all allegations of abuse or neglect will be reviewed by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 9) On a daily basis, all resident behavior sheets are reviewed by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant for unusual behaviors. Any new behaviors or concerns will be care planned immediately by the MDS Coordinator and MDS Coordinator Assistant. 10) During the weekly Quality Assurance (QA) meeting all non-interviewable (Brief Interview for Mental Status score less than 8) residents' skin assessments are reviewed for injuries of unknown origin by the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. 11) An Investigation Check List was compiled by the DON and SSD to ensure investigations were completed according to facility policy. The checklist included: a. Who was notified of the alleged abuse. b. Who completed the investigation. c. Who reviewed the information prior to closing the investigation. A more complete history of the resident involved, to include: cognitive function, Brief Interview for Mental Status (BIMS) score, and any pertinent medical and psychiatric history. All investigations are to be completed by the SSD or the DON. All past facility investigations (since last survey in April 2015) were reviewed by the SSD on 02/09/16. The SSD used the Investigation Check List and the facility's Abuse and Neglect policy to review the investigations to ensure a thorough investigation had been completed. 12) All Department Managers were in-serviced on the Investigation Check List by the SSD or DON on 02/05/16. 13) An Investigation Protocol Check List was developed by the SSD and DON to assist during the beginning of any abuse or neglect investigation. The SSD and DON in-serviced the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant on 02/08/16 regarding the Investigation Protocol Check List. 14) The facility Abuse and Neglect policy was updated to include that all Department Managers (Administrator, DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant) were to review any investigation findings and address any concerns before finalizing an investigation. The Department Managers were in-serviced by the SSD. 15) All interviewable (BIMS score of 8 or above) residents were interviewed by the SSD and MDS Coordinator on 02/04/16 and 02/05/16. The residents were asked direct questions regarding the care they receive and any problems with facility staff. a. Resident #4 made a reportable allegation during the interviews on 02/05/16 at 3:15 PM. The resident stated a staff member man handled the resident when assisting him/her to bed. The resident was unable to determine a specific date of the incident. The resident stated the staff member urged him/her into bed, assisting the resident by holding his/her arm in a manner that made the resident feel man handled. The resident was unable to name the staff member and no staff members matched the resident's description; therefore, no staff member was suspended. i) The SSD contacted the Office of Inspector General (OIG) and Protection and Permanency (P & P) regarding the incident. ii) A skin assessment was immediately completed by the MDS Coordinator and no areas of concern were found. iii) The resident was placed on every 15-minute safety checks. iv) The Abuse and Neglect Investigation was initiated by the SSD on 02/05/16 and was completed on 02/10/16. 16) Skin assessments of non-interviewable residents (BIMS score of 8 or less) completed since 01/13/16 were reviewed by the Restorative Supervisor and the MDS Coordinator Assistant on 02/04/16. No concerns for suspicious bruising or unknown injury were determined during the review. 17) SRNA #1 was initially suspended pending the facility investigation on 01/13/16; however, the SRNA was allowed to return to work on 01/22/16. The SRNA was suspended again on 01/29/16, pending review of the investigation by the SSD. Upon completion of the review, SRNA #1 was terminated on 02/08/16. 18) SRNA #2 contacted the facility and quit on 01/29/16 without notice. 19) RN #1 was suspended on 01/29/16 and then terminated on 02/10/16. 20) The facility determined only employees who were found unsubstantiated of abuse or neglect will be allowed to return to work. The employee will be in-serviced by the SSD on the updated Abuse and Neglect policy before providing any direct care. 21) The MDS staff (MDS Coordinator and MDS Coordinator Assistant) was in-serviced on 01/29/16 by the DON regarding care planning resident behaviors. All nurses were in-serviced by the MDS Coordinator and MDS Coordinator Assistant on 02/01/16 concerning care planning resident behaviors. a. Resident #1's care plan was updated on 01/29/16 by the MDS Coordinator. b. All residents were reviewed for behaviors on 01/29/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. i) Fourteen residents' care plans were updated on 02/03/16 by the MDS Coordinator for behaviors. 22) Facility in-services including Abuse and Neglect Policy and Reviewing/Revising Care Planned Behaviors were repeated on 02/15/16 by the DON, SSD, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant. ***The State Survey Agency (SSA) validated removal of the immediate jeopardy as follows: 1) Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 who was also the facility Restorative Supervisor at 12:39 PM, the MDS Coordinator at 11:06 PM, and the MDS Coordinator Assistant at 10:39 AM revealed they were responsible for reviewing the facility's investigation dated 01/13/16 regarding Resident #1. Further interview with the team revealed they reviewed the investigation to determine the causes of the Immediate Jeopardy (IJ) and determined interventions to implement corrective action. 2) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed the Administrator, DON, RN Supervisor, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD. Interview with the SSD on 02/11/16 at 10:48 AM revealed he was responsible to compile the facility's Abuse and Neglect Inservice for staff. Interviews conducted on 02/11/16 with the Administrator at 1:05 PM, the DON at 12:43 PM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the MDS Coordinator at 11:06 AM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were in-serviced by the SSD on 02/01/16 regarding the facility's Abuse and Neglect policy. 3) Review of the facility's Abuse and Neglect Training Inservice roster, dated 02/01/16, revealed facility staff training was initiated on 02/01/16 and concluded on 02/04/16. Review of the facility's Abuse and Neglect posttests revealed all facility staff was given and successfully completed an in-service posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with the DON at 12:43 PM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the MDS Coordinator Assistant at 10:39 AM confirmed they were responsible to in-service all facility staff and all in-services were completed by 02/04/16. Further interview revealed all facility staff was given a posttest covering the in-service material, and all staff completed the posttest with a 100 percent pass rate. Interviews conducted on 02/11/16 with SRNA #3 at 10:59 AM, SRNA #4 at 11:01 AM, SRNA #5 at 11:03 AM, Maintenance Staff Member #1 at 11:02 AM, and Maintenance Staff Member #2 at 11:04 AM confirmed that facility staff was in-serviced regarding the Abuse and Neglect policy and that staff was given a posttest after completing the in-service. 4) Review of the facility's Addendum of Notification Protocol roster revealed that all facility charge nurses were in-serviced by 02/09/16. Interviews conducted on 02/11/16 with the DON at 12:43 PM and the RN Supervisor at 12:20 PM revealed they in-serviced all facility charge nurses regarding the Addendum of Notification Protocol by 02/09/16. Interviews conducted on 02/11/16 with LPN #4 at 11:26 AM, RN #4 at 11:30 AM, and RN #2 at 11:38 AM confirmed they were in-serviced by the DON and RN Supervisor regarding the Addendum of Notification Protocol to include who to notify in a case of suspected abuse or injury of unknown origin. 5) Review of the in-service training and posttests for employees hired after 02/01/16 revealed they were in-serviced regarding Abuse and Neglect, Care Planning Behaviors, and Documenting Behaviors. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed all newly hired staff will be in-serviced regarding Reporting Abuse and Neglect, Care Planning, and Documenting Behaviors. Further interview confirmed all facility staff will receive bi-annual training on Abuse and Neglect. 6) Review of the Resident Rights Compliance Rounds, dated 02/04/16, 02/05/16, and 02/09/16 revealed five different residents (with a BIMS score of 8 or above) throughout the building were interviewed by the SSD weekly for concerns of abuse and neglect. Review of the Abuse and Neglect Weekly Compliance Monitoring, dated 02/01/16 and 02/08/16, revealed five different employees were interviewed by the SSD weekly to verify their comprehension and compliance with the facility's Abuse and Neglect policy. Interview with the SSD on 02/11/16 at 10:48 AM confirmed that it was his responsibility to develop and utilize the assessment tools to interview five residents and five employees weekly regarding abuse and neglect. The SSD stated he will be responsible for addressing any allegations of abuse or neglect immediately per facility policy. Interview with LPN #4 on 02/11/16 at 11:26 PM revealed she was interviewed by the SSD on 02/10/16 regarding the facility's Abuse and Neglect policy. 7) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed the RN Supervisor reviewed the 24-hour report sheets and physician's orders [REDACTED]. Interview with the RN Supervisor at 12:20 PM revealed she was responsible to review all the 24 Hour Report Sheets and physician's orders [REDACTED]. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed the RN Supervisor reviews the 24 Hour Report Sheets and physician's orders [REDACTED]. 8) Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM revealed all allegations of abuse or neglect were reviewed during the daily Department Head Meeting. 9) Review of the daily Department Head Meeting Minutes starting 02/05/16 revealed Resident Behavior Sheets were reviewed daily during the meeting. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the MDS Coordinator at 11:06 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM confirmed resident behavior sheets are reviewed daily. Further interviews on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to care plan any new resident behaviors immediately. 10) Review of the Quality Assurance (QA) meeting minutes, dated 02/08/16, revealed all non-interviewable (BIMS score less than 8) residents' skin assessments were reviewed for injuries of unknown origin. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed all non-interviewable residents' skin assessments were reviewed for injuries of unknown origin and no concerns were identified. 11) Review of the Investigation Check List revealed it included who was notified of the alleged abuse, who completed the investigation, who reviewed the information prior to closing the investigation, and a more complete history of the resident involved. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they were responsible to compile an Investigation Check List and were responsible to complete all facility investigations. Further interview with the SSD on 02/11/16 at 10:48 AM revealed he reviewed all past facility investigations since April 2015 on 02/09/16 and no concerns were identified. The SSD stated he used the Investigation Check List and the facility's Abuse and Neglect policy to review all the past investigations. 12) Review of the Abuse and Neglect Training Inservice Investigation Revision, dated 02/05/16, revealed all Department Managers were in-serviced by the SSD. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced by the SSD on 02/05/16 regarding the Investigation Check List. 13) Review of the Investigation Protocol Check List in-service roster, dated 02/08/16, revealed the Administrator, Restorative Supervisor, MDS Coordinator, and MDS Coordinator Assistant were in-serviced by the SSD and DON. Interviews on 02/11/16 with the SSD at 10:48 AM and the DON at 12:43 PM revealed they developed the Investigation Protocol Check List to assist during the beginning of any abuse or neglect investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the Investigation Protocol Check List. 14) Review of the facility's Abuse and Neglect policy revealed the policy had been updated to instruct all Department Managers to review any investigation findings and address any concerns before finalizing an investigation. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the MDS Coordinator at 11:06 AM, LPN #3 (Restorative Supervisor) at 12:39 PM, the RN Supervisor at 12:20 PM, the DON at 12:43 PM, and the Administrator at 1:05 PM confirmed they were in-serviced regarding the updated Abuse and Neglect policy. 15) Review of the statement made by the SSD, dated 02/05/16, revealed all interviewable (BIMS score of 8 or above) residents were interviewed. Interviews conducted on 02/11/16 with the SSD at 10:48 AM and the MDS Coordinator at 11:06 AM revealed they were responsible to interview all capable residents and they asked direct questions regarding care and issues with the facility staff. Interviews with Resident B on 02/11/16 at 11:40 AM and Resident D at 11:45 AM revealed facility staff had asked the resident about concerns for abuse, neglect, and issues with facility staff. Review of the facility's investigation, dated 02/05/16, revealed the facility had followed policy to complete a thorough investigation. Review of Resident #4's safety check sheets, revealed the facility placed Resident #4 on 15-minute safety checks after the allegation was made on 02/05/16 and continued until present (02/11/16). Interview with the SSD on 02/11/16 revealed the investigation was initiated on 02/05/16 and finalized on 02/10/16 after the findings were reviewed during the Department Head Meeting. 16) Review of the statement made by the Restorative Supervisor and the MDS Coordinator Assistant, dated 02/04/16, revealed all non-interviewable (BIMS scores of 8 or below) residents' skin assessments completed since 01/13/16 were reviewed. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 PM and LPN #3 (Restorative Supervisor) at 12:39 PM revealed they reviewed all of the non-interviewable skin assessments and no concerns were identified. 17) Review of statements made by the DON and RN Supervisor, dated 01/29/16, revealed SRNA #1 was suspended on 01/29/16, and then later terminated on 02/08/16. Interviews with the RN Supervisor on 02/11/16 at 12:20 PM and the DON at 12:43 PM confirmed SRNA #1 was suspended and then later terminated on 02/08/16. 18) Interview with SRNA #2 on 01/27/16 at 3:25 PM revealed she quit the facility without notice. 19) Review of the statements made by the DON and RN Supervisor revealed RN #1 was suspended on 01/29/16 and terminated on 02/10/16. Interviews on 02/11/16 with the RN Supervisor at 12:20 PM and the DON at 12:43 PM revealed RN #1 was suspended and later terminated. 20) Interview with the SSD on 02/11/16 at 10:48 AM revealed any employee that was named in an allegation of abuse or neglect that was allowed to return to work will be in-serviced on the updated Abuse and Neglect policy prior to providing any direct care. 21) Review of the New Behavior Care Planning Policy in-service roster, dated 01/29/16, revealed the MDS Coordinator and MDS Coordinator Assistant were in-serviced by the DON. Review of the New Behavior Care Planning Policy in-service roster, dated 02/01/16, revealed all facility nurses were in-serviced by the MDS Coordinator and the MDS Coordinator Assistant. Interviews on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM and the MDS Coordinator at 11:06 AM confirmed they were responsible to in-service all nursing staff regarding care planning resident behaviors. Interviews on 02/11/16 with LPN #4 at 11:26 AM, RN #4 at 11:30 AM, and RN #2 at 11:38 AM revealed they were in-serviced regarding care planning resident behaviors. a. Review of Resident #1's care plan revealed the care plan was updated on 01/29/16 to include a history of confusion. Interview with the MDS Coordinator on 02/11/16 at 11:06 AM confirmed Resident #1's care plan was updated on 01/29/16. b. Review of the MDS Behavior Assessment Tool, dated 01/29/16, revealed all residents were reviewed for behaviors. Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM confirmed all residents were reviewed for behaviors. i) Review of the care plans revealed 14 residents' care plans were updated on 02/03/16. Interview with the MDS Coordinator on 02/11/16 at 11:06 AM revealed it was her responsibility to review and update the residents' care plans that were identified to have new behaviors. 22) Interviews conducted on 02/11/16 with the MDS Coordinator Assistant at 10:39 AM, the SSD at 10:48 AM, the RN Supervisor at 12:20 PM, LPN #3 (Restorative Supervisor) at 12:39 PM, and the DON at 12:43 PM revealed facility in-services including Abuse and Neglect Policy and Reviewing/Revising Care Plan Behaviors will be repeated on 02/15/16.

Based on interviews, closed medical record review, hospital record review and review of the facility's policy, it was determined the facility failed to immediately notify an interested family member and/or the resident's physician when there was a significant change in the resident's status and a need to alter the treatment for one of four sampled residents (Resident #1). Resident #1 was admitted on [DATE], with three surgical incisions to the right leg. The resident had a follow-up appointment on 06/06/13 and at that time was diagnosed with [REDACTED]. Resident #1 was admitted to the hospital for treatment of the infection. However, based on documentation and interviews, the facility failed to ensure Resident #1's interested family member and/or the resident's physician had been notified of the changes in the surgical incisions that occurred prior to the follow-up visit conducted on 06/06/13, and that had the potential to require physician intervention. (Refer to F278 and F309.) The findings include: Review of the facility's undated policy entitled "Notification of Changes in a Resident's Condition" revealed a licensed nurse would be responsible for assessing the resident and notifying the resident's attending physician, the resident's responsible party, the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator when there was a significant change in the resident's status and/or condition. The review revealed staff was responsible to document all changes in the resident's condition on the 24-hour report and the three-part condition change form. Review of Resident #1's closed medical record revealed the facility admitted the resident for rehabilitation on 05/22/13, with a [DIAGNOSES REDACTED]. Staff conducted a skin assessment of Resident #1 upon admission and noted the resident had three incisions; the first incision had fifteen staples, and the second and third incisions had four staples each. Review of physician's orders and the Treatment Administration Records (TARs) from 05/22-29/13, revealed staff was to monitor the surgical sites to the resident's right hip and upper outer leg twice a day. Review of Resident #1's medical record, which included the skin assessments and the Treatment Administration Records (TARs), revealed facility staff failed to document a description of the appearance of the three incisions to the resident's hip from the time of admission (05/22/13) until the resident's discharge (06/06/13). Review of Resident #1's Physician Notes from a follow-up appointment on 05/29/13, revealed the resident had some "[MEDICAL CONDITION]" (inflammation) to the distal end of the incision with no active drainage noted. Continued review of documentation by the physician on 05/29/13, revealed Resident #1's physician ordered staff to administer 500 milligrams (mg) of Keflex (antibiotic) to the resident three times a day. The physician also requested staff to assess the incisions on a daily basis when the dressings were changed and to arrange for a follow-up appointment on 06/06/13. The review revealed, "the resident can follow up sooner if there are increasing signs of infection." Review of Resident #1's TARs revealed from 05/30/13 through 06/06/13, staff applied an Allevyn patch (adhesive surgical dressing to aid healing) to the surgical sites on the resident's right hip and upper outer leg every day as ordered during the resident's follow-up appointment on 05/29/13. Based on documentation, staff also continued to monitor the resident's surgical sites twice a day, as previously ordered. However, staff failed to document a description of the resident's surgical incisions. Review of a Discharge Summary by Occupational Therapist (OT) #1 revealed Resident #1 was discharged from therapy on 06/06/13, after a "follow-up" appointment with the physician. According to documentation by the therapist, Resident #1 was admitted to the hospital on [DATE], due to Osteo[DIAGNOSES REDACTED] (infection of the bone). Review of documentation in the hospital medical record by nursing staff, dated 06/06/13, at 4:30 PM revealed the incision to Resident #1's lateral right hip was red, warm, and had a "thick yellow drainage" to the distal parts of the incision. In addition, nursing documentation in the hospital medical record dated 06/06/13, at 9:00 PM revealed the surgical wounds to the resident's right hip were "poorly approximated" (areas of separation) with "yellow drainage" and redness noted. Review of a History and Physical documented in the hospital medical record by a physician on 06/06/13, revealed Resident #1 had been seen in the physician's office "a week ago" (05/29/13) and the resident's lower incision was "slightly open and draining." The review revealed on 06/06/13 the resident was found to have an infection to the right leg incision. Further review revealed Resident #1 was admitted to the hospital for an Incision and Drainage (I&D) of the incision. Review of Physician's Progress Notes/doctor's orders in the hospital medical record dated 06/06/13, revealed the orthopedic physician noted Resident #1's surgical incision had [DIAGNOSES REDACTED] (reddening of the skin due to inflammation) and purulent drainage (a discharge of pus). Resident #1 was admitted to the hospital for an Incision and Drainage (I&D) of the incision due to an abscess of the surgical incisions. Review of a consultation from an Infectious Disease physician, dated 06/06/13, revealed Resident #1 reported having an increase in pain and discharge from the right hip. Continued review of the physician's consult revealed Resident #1 had been placed on oral antibiotics; the pain and drainage worsened; and, there was some dehiscence (opening) of the incision. The documentation revealed the resident was admitted to the hospital for further evaluation and a plan to undergo an "irrigation and debridement" of the right hip incision. The documentation also revealed cultures of the surgical incisions were obtained and antibiotics were initiated. A review of the hospital Discharge Summary dated 06/11/13, revealed Resident #1 was admitted on [DATE], and was discharged home on[DATE], with a [DIAGNOSES REDACTED]." Interview conducted via telephone on 06/26/13, at 1:00 PM with Resident #1 revealed that prior to the resident's admission to the facility, a nurse at the hospital applied a dressing to the incisions on the resident's right hip and leg, and the dressings remained in place when the resident was admitted to the facility on [DATE]. The resident stated nursing staff at the facility did not change the dressing to his/her right hip and leg for the first week he/she was at the facility. According to Resident #1, when he/she questioned why the dressing was not being changed the nursing staff informed the resident there was no physician's order to change the dressing. Resident #1 reported that during the follow-up appointment on 05/29/13, the physician was upset and questioned the resident concerning the dressing being soiled and not changed. The resident informed the physician the staff did not have an order for [REDACTED]. The resident stated that one nurse at the facility said the incisions "didn't look good" but never explained what that meant. The interview revealed after a follow-up visit with the physician on 06/06/13, the resident was admitted to the hospital where the incisions were re-opened and cleansed. Further interview with Resident #1 revealed at the time of the interview he/she continued to receive intravenous (IV) antibiotics and was to continue the antibiotics for three weeks. Resident #1 had been discharged from the facility on 06/06/13, and an observation of the resident's incisions was not conducted. An attempt to interview Resident #1's family member on 06/25/13, at 8:25 AM was unsuccessful. However, review of correspondence dated 06/17/13, from Resident #1's family member revealed the resident had informed the family member the dressings to his/her surgical incisions had not been not changed during the stay at the facility. The letter revealed the family member was unaware of the infection to the incisions until the resident's follow-up appointment with the surgeon on 06/06/13. Interview conducted on 06/25/13, at 3:50 PM with Licensed Practical Nurse (LPN) #5 and review of documentation on the TARs in Resident #1's medical record at the facility revealed the LPN assessed the resident's incisions at the facility on 05/24-26/13, and on 06/01-06/13. The interview revealed the incision had a slight amount of redness at the distal end of the incision which worsened when dressings were initiated on 05/29/13. LPN #5 stated she noticed a change in the condition of the resident's surgical incisions; however, according to LPN #5, she did not notify the physician because the physician had placed the resident on antibiotics on 05/29/13 and had scheduled the resident for a follow-up appointment. Interview conducted on 06/25/13, at 7:00 PM with LPN #6 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/22-23/13, 05/27/13, 05/31/13, and on 06/01-02/13, and 06/05-06/13. The interview revealed the incisions were slightly red upon admission and increased in redness during the resident's stay; however, LPN #6 stated she had not notified the resident's physician or the resident's family member of the change in the status of the resident's incisions. Interviews conducted on 06/25/13, at 5:50 PM with the DON and Registered Nurse (RN) #2 confirmed the facility's policy was to notify the resident's physician of changes in a resident's condition. The interview revealed the DON and RN #2 were not aware there had been a change in Resident #1's incision, and were not aware if facility staff had notified the resident's family member or physician of the changes.

Based on interview, closed medical record review, hospital record review, and review of the facility's policy, it was determined the facility failed to ensure assessments accurately reflected the resident's status for one of four sampled residents (Resident #1). Resident #1 was admitted to the facility with three surgical incisions to the right leg. However, based on documentation and staff interviews, the facility failed to document assessments of the status of the resident's surgical incisions in an effort to coordinate the resident's care with the appropriate health professionals. On 06/06/13, the resident was assessed by a physician during a follow-up appointment and diagnosed with [REDACTED]. (Refer to F309.) The findings include: Review of the facility's undated policy entitled "Wound Documentation" revealed staff was responsible to document daily on all wounds which included pressure ulcers, surgical wounds, and skin tears. The policy revealed the staff would document the wound's status on the back of the Treatment Administration Record (TAR). Review of Resident #1's closed medical record revealed the facility admitted the resident for rehabilitation on 05/22/13, with a [DIAGNOSES REDACTED]. At the time of admission, facility staff assessed the resident and noted the resident had a surgical incision that had fifteen staples and two surgical incisions that had four staples each. Review of physician's orders [REDACTED]. However, based on review of documentation in Resident #1's medical record, including the skin assessments and the Treatment Administration Record (TAR), facility staff failed to document a description of the appearance of the three incisions and had only documented how many staples were in each incision. Review of Resident #1's closed medical record revealed an Admission Minimum Data Set (MDS) assessment dated [DATE]. The review revealed the resident's cognition was intact. The MDS assessment also revealed the resident had surgical wounds; however, facility staff failed to document the appearance of the three incisions. Further review of the clinical record revealed Resident #1 was assessed by a physician during a follow-up appointment on 05/29/13; and documentation from the follow-up appointment revealed the physician requested for staff to administer 500 milligrams (mg) of Keflex (antibiotic) three times a day due to inflammation to the distal end of the surgical incision. In addition, the physician requested staff to monitor the resident's wounds/incisions and change the dressings to the wounds/incisions on a daily basis. Resident #1 was to return to the physician's office for a follow-up appointment on 06/06/13 or "sooner" if there were increasing signs of infection. Review of documentation by the physician following the follow-up visit on 05/29/13, revealed Resident #1 had "[MEDICAL CONDITION]" (inflammation which is red, hot, and painful) of the incisions "distally," with no active drainage noted. Review of documentation on the TARs revealed staff applied an Allevyn patch (surgical dressing) to the surgical sites on Resident #1's right hip and upper outer leg every day from 05/30/13 through 06/06/13. Although facility staff had noted the resident's incisions had been monitored twice a day, facility staff failed to document an assessment, including a description, of the status of the surgical incisions. Review of documentation by Occupational Therapist (OT) #1 dated 06/11/13, revealed Resident #1 was admitted to a hospital after a follow-up visit with the physician on 06/06/13, secondary to Osteo[DIAGNOSES REDACTED] (bone infection). Review of nurse's notes in Resident #1's hospital medical record dated 06/06/13, at 4:30 PM revealed the surgical incision to Resident #1's right hip was red, warm, and had "thick yellow" drainage at the distal parts of the incision. Further review of the hospital's nurse's notes dated 06/06/13, at 9:00 PM revealed the surgical incisions on the resident's right hip were poorly approximated (edges are brought together without areas of separation), were red, and had "yellow drainage." Review of a History and Physical documented by the physician at the time of Resident #1's admission to the hospital on [DATE], revealed Resident #1 had been seen in the physician's office a "week ago" (05/29/13) and the resident's lower incision was slightly opened and draining. Further review revealed on 06/06/13, the resident was admitted to the hospital for an Incision and Drainage (I&D) of the incision due to an infection. Resident #1 was discharged home from the hospital on [DATE], and an observation of the resident's incision was not conducted during the investigation. Review of progress notes/doctor's orders dated 06/06/13, revealed an Orthopedic Physician at the hospital assessed Resident #1 and noted the resident's incision was red and had a "purulent" discharge. Resident #1 was admitted for an Incision and Drainage (I&D) of an abscess at the surgical incision. Review of an Infectious Disease Consultation dated 06/06/13, revealed Resident #1 had reported an increase in pain and a discharge from the right hip. Documentation revealed the resident was placed on oral antibiotics, the pain and drainage worsened, the incision had some dehiscence, and the resident was admitted to the hospital for further evaluation/treatment. In addition, a review of Resident #1's hospital Discharge Summary dated 06/11/13, revealed the resident was admitted on [DATE], and was discharged home on[DATE], with a [DIAGNOSES REDACTED]. The Discharge Summary revealed the "patient unfortunately did not have (his/her) dressing changed at least for 10 days." Interview conducted on 06/25/13, at 2:30 PM with Licensed Practical Nurse (LPN) #1 and review of the TARs for Resident #1 revealed the LPN assessed the resident's incisions on 05/22/13, 05/23/13, 05/27/13, and 05/28/13, but failed to document a description of the appearance of the resident's incisions. The interview with LPN #1 revealed there was no dressing to the resident's incisions and "no redness or drainage" noted. However, LPN #1 failed to document a description of the resident's incisions. Interview conducted on 06/25/13, at 2:50 PM with LPN #2 and review of the TARs for Resident #1 revealed the LPN assessed the resident's incisions on 05/28-30/13. LPN #2 stated the resident's incision was covered with a dressing and when the LPN changed the dressing there was no redness or drainage noted. However, the LPN failed to document a description of the resident's incisions. Interview conducted on 06/25/13, at 3:05 PM with LPN #3 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/24-26/13 and the incisions were left open to air with no redness or drainage noted. Further interview and review of the TAR revealed LPN #3 also assessed and provided incision care for Resident #1 on 06/03-04/13, and with the dressing changes there was no redness or drainage of the incisions noted at that time. However, LPN #3 failed to document a description of the resident's incisions. Interview conducted on 06/25/13, at 3:30 PM with LPN #4 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/24-26/13 and again on 05/29/13. The LPN stated the resident's incisions were covered with a dressing and when the LPN changed the dressing there was no redness or drainage noted. However, the LPN failed to document a description of the resident's incisions. Interview conducted on 06/25/13, at 3:50 PM with LPN #5 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/24-26/13, and on 06//01-06/13. The interview revealed the incision had a slight amount of redness at the distal end of the incision which worsened when the dressing started being applied. LPN #5 stated she noticed a change in the incisions but had failed to document a description of the resident's incisions. Interview conducted on 06/25/13, at 7:00 PM with LPN #6 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/22/13, 05/23/13, 05/27/13, 05/31/13, 06/01/13, 06/02/13, 06/05/13, and 06/06/13. The interview revealed the incision was slightly red upon admission and increased in redness during the resident's stay at the facility. However, the LPN failed to document a description of the resident's incisions. Interviews conducted on 06/25/13, at 5:50 PM with the Director of Nursing (DON) and Registered Nurse (RN) #2 revealed facility staff was to document an assessment of a resident's wounds on a daily basis in accordance with the facility's policy. According to interview with the DON and RN #2, the wound assessments were to be documented on the back of the TARs. After reviewing Resident #1's closed medical record the DON and RN #2 confirmed there was no documented assessment of the resident's incisions or of a change in the condition of the resident's incisions.

Based on interview, closed medical record review, and hospital record review, it was determined the facility failed to develop a care plan to describe the services to be furnished to attain or maintain the highest practicable physical well-being for one of four sampled residents (Resident #1). Resident #1 was admitted to the facility with three surgical incisions to the right leg; however, the facility failed to develop a care plan to address the care to be provided to the surgical incisions. On 06/06/13, Resident #1 was assessed by the physician during an office visit and diagnosed with [REDACTED].) The findings include: According to the Director of Nursing (DON), although the facility did not have a written policy for the development of a care plan upon admission, staff was to develop an admission working care plan and a nurse aide care plan. According to the DON, the facility had an "Admission Check List" which was completed by the admitting nurse upon each resident's admission to ensure staff developed the admission working care plan and the aide care plan. The DON reported that the Minimum Data Set (MDS) Coordinator also utilized the "Admission Check List" to develop the comprehensive care plan within 21 days of admission. Review of the closed medical record for Resident #1 revealed the facility admitted the resident on 05/22/13 for rehabilitation. Resident #1's [DIAGNOSES REDACTED]. A skin assessment conducted upon admission to the facility revealed the resident had three intact incisions; the first incision had fifteen staples and the second and third incision both had four staples. Review of Resident #1's medical record, including the Treatment Administration Records (TARs) and physician's orders [REDACTED]. A review of documentation from a follow-up appointment on 05/29/13 revealed the resident's physician ordered 500 milligrams (mg) of Keflex (an antibiotic) to be administered to Resident #1 three times a day. In addition, the physician requested staff to conduct assessments of the resident's surgical incisions on a daily basis with dressing changes. Documentation revealed Resident #1 had a follow-up appointment with the physician on 06/06/13, and was diagnosed with [REDACTED]. Review of Resident #1's hospital Discharge Summary dated 06/11/13, revealed the resident was admitted to the hospital on [DATE], and was discharged home on[DATE], with a [DIAGNOSES REDACTED]." Review of Resident #1's care plan revealed facility staff had failed to ensure a care plan had been developed to address the resident's incisions, including the potential for infection, and failed to develop interventions to ensure the resident's surgical incision healed without complications. Interview conducted on 06/25/13, at 5:50 PM with Registered Nurse (RN) #2 revealed the nurse who completed the admission was responsible for developing a working care plan for residents in the facility based on their care needs. The interview revealed the MDS Coordinator would develop a comprehensive care plan within 21 days of admission along with the completion of the MDS assessment. RN #2 stated Resident #1 had only been a resident in the facility for 16 days and a comprehensive care plan had not been developed. RN #2 acknowledged the "working" care plan failed to include interventions related to the potential for the development of infection of the surgical incisions. Interview conducted on 06/25/13, at 7:00 PM with LPN #6 revealed the nurse performed the admission assessment for Resident #1 on 05/22/13, and the working care plan. However, the working care plan failed to address the care to be provided to the resident's incisions.

Based on interview, closed medical record review, hospital record review and review of the facility's policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received the necessary care and services to maintain the highest practical physical well-being. Resident #1 was admitted to the facility on [DATE], with three (3) surgical incisions to the right leg. On 06/06/13, Resident #1 was assessed during a follow-up visit with the physician and diagnosed to have infection to the incisions. Resident #1 was admitted to the hospital on [DATE], for treatment of [REDACTED]. incisions, including significant changes in the appearance of the surgical incisions. (Refer to F157, F278, and F279) The findings include: Review of the facility's policy entitled "Notification of Changes in a Resident's Condition," undated, revealed staff was to notify the resident, the resident's attending physician, the resident's responsible party, the Director of Nursing and the MDS Coordinator of changes in the resident's condition. The policy revealed a licensed nurse would be responsible for assessing the resident and notifying the resident's attending physician, the resident's responsible party, the Director of Nursing and the MDS Coordinator when there had been a significant change in the resident's status. The review revealed staff was responsible to document all changes in the resident's condition on the 24-hour report and the three-part condition change form. Review of the facility's policy entitled "Wound Documentation," undated, revealed staff was responsible to document daily on all wounds which included pressure ulcers, surgical wounds, and skin tears. The policy revealed the staff would document the wound's status on the back of the Treatment Administration Record (TAR). Review of Resident #1's closed medical record revealed the facility admitted the resident for rehabilitation on 05/22/13 with a [DIAGNOSES REDACTED]. Facility staff conducted a skin assessment upon the resident's admission to the facility and noted the resident had three (3) intact incisions that included one (1) with fifteen (15) staples and two (2) with four (4) staples each. However, review of Resident #1's medical record, including the skin assessments and the Treatment Administration Records (TARs), revealed facility staff failed to document a description of the appearance of the three (3) incisions. Review of the TARs and physician's orders for May 2013 revealed staff was to monitor the surgical sites to the right hip and upper outer leg twice a day; however, there were no treatments ordered for the incisions until after a follow up appointment on 05/29/13, seven (7) days after the resident's admission to the facility. Review of documentation from the follow up appointment revealed Resident #1's had inflammation to the distal section of the incision and the physician requested staff to administer 500 milligrams of Keflex (antibiotic) to Resident #1 three times a day; to conduct daily incision assessment with dressing changes; and for the resident to return to the physician's office on 06/06/13, for a follow-up appointment or "sooner if there are increasing signs of infection". Review of Resident #1's clinical record revealed from 05/30/13, through 06/06/13, staff applied an Alleyvn patch (surgical dressing) to Resident #1's surgical site on the right hip and upper outer leg every day; however, staff failed to document a description of the status of the surgical incisions. Review of Resident #1's care plan revealed facility staff had failed to ensure a care plan had been developed to address the resident's incisions, including the potential for infection, and failed to develop interventions to ensure the resident's surgical incision healed without complications. Interview conducted on 06/25/13, at 5:50 PM with Registered Nurse (RN) #2 revealed the nurse who completed the admission was responsible for developing a working care plan for residents in the facility based on their care needs. The interview revealed the MDS Coordinator would develop a comprehensive care plan within twenty-one (21) days of admission along with the completion of the MDS assessment. RN #2 stated Resident #1 had only been a resident in the facility for sixteen (16) days and a comprehensive care plan had not been developed. RN #2 acknowledged the "working" care plan failed to include interventions related to the potential for the development of infection of the surgical incisions. Documentation in Resident #1's medical record revealed Resident #1 was admitted to a hospital on [DATE], secondary to an infection of the surgical incisions. Review of a hospital History and Physical dated 06/06/13, revealed Resident #1 was seen in the physician's office "a week ago" (05/29/13) and the resident's lower incision was slightly opened and draining. The review revealed the physician assessed Resident #1 again on 06/06/13, and documented the resident had an infection to the right leg incision and was admitted to the hospital. Review of documentation by an Orthopedic physician at the hospital on [DATE], revealed Resident #1 had [DIAGNOSES REDACTED] (reddening of the skin due to inflammation) and purulent drainage (discharging of pus) from the surgical incision and was admitted to the hospital due to an abscess (a collection of pus) of the incisions. An Infectious Disease Consultation on 06/06/13 revealed Resident #1 had an increase in pain and discharge from the right hip incision and had been placed on oral antibiotics. Based on the Infectious Disease Consultation, the resident's pain and drainage from the incision had worsened, some dehiscence of the incision had occurred, and Resident #1 was admitted to the hospital for further evaluation. Documentation revealed an irrigation and debridement of the surgical incision on Resident #1's right hip was conducted, cultures were obtained, and antibiotics were initiated. A review of Resident #1's hospital Discharge Summary dated 06/11/13, revealed the resident had been admitted to the hospital on [DATE], and was discharged home on[DATE], with a [DIAGNOSES REDACTED]. According to the Discharge Summary, the "Patient unfortunately did not have (his/her) dressing changed at least for 10 days." Interview conducted on 06/26/13 at 1:00 PM, with Resident #1 revealed a nurse at the hospital had applied a dressing to the incisions on the right hip and leg which were in place when the resident was admitted to the facility on [DATE]. The resident stated nursing staff at the facility did not change the dressing to his/her right hip and leg for the first week he/she was at the facility. According to Resident #1, when he/she questioned why the dressing was not being changed the nursing staff informed the resident there was no physician's order to change the dressing. Resident #1 reported that during the follow up appointment on 05/29/13, the physician was upset and questioned the resident concerning the dressing being soiled and not changed. The resident informed the physician the staff did not have an order for [REDACTED]. The interview revealed after a follow up visit with the physician on 06/06/13, the resident was admitted to the hospital where the incisions were re-opened and cleaned out. Resident #1 stated he/she was still taking intravenous (IV) antibiotics and was to continue the antibiotics for the next three (3) weeks. An attempt to interview Resident #1's family member on 06/25/13, at 8:25 AM was unsuccessful. However, a review of correspondence, dated 06/17/13, from Resident #1's family member revealed the resident had informed the family member the dressings to his/her surgical incisions had not been not changed during his/her stay at the nursing home. Further review revealed Resident #1 and the family member were unaware of the infection to the incisions until the resident's follow up appointment with the surgeon on 06/06/13. Interview on 06/25/13, at 2:30 PM with Licensed Practical Nurse (LPN) #1 revealed the LPN assessed the resident's incisions on 05/22/13, 05/23/13, 05/27/13, and 05/28/13, and had failed to document the appearance of the resident's surgical incisions. LPN #1 stated the resident's incisions had been left open to air with no redness or drainage noted. Interview conducted on 06/25/13, at 2:50 PM with LPN #2 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/28-30/13. According to LPN #2, the incision was covered with a dressing and when she changed the dressing she had not observed any redness or drainage of the incisions, and had failed to document the assessment. Interview conducted on 06/25/13 at 3:05 PM with LPN #3 revealed the LPN assessed the resident's incisions on 05/24-26/13, and the incisions had been left open to air with no redness or drainage noted. Further interview and review revealed LPN #3 also assessed and provided incision care for Resident #1 on 06/03-04/13, with no redness or drainage noted when the dressing was changed; however, there was no documentation of the appearance of the incisions. Interview conducted on 06/25/13, at 3:30 PM with LPN #4 revealed the LPN assessed the resident's incisions on 05/24-26/13, and again on 05/29/13. The LPN stated the resident's incisions were covered with a dressing and when the dressing was changed there was no redness or drainage noted; however, there was no documentation of the appearance of the incisions. Interview conducted on 06/25/13, at 3:50 PM with LPN #5 and review of Resident #1's TARs revealed the LPN assessed the resident's incisions on 05/24-26/13 and on 06//01-06/13. The interview revealed the incision had a slight amount of redness at the distal end of the incision which worsened when the dressing started being applied and would have been documented on the TARs. LPN #5 stated she noticed a change in the incisions; however, the LPN stated she failed to document the description of the incisions and had not notified the resident's family member or the resident's physician because the physician had started the resident on an antibiotic and already scheduled the resident for a follow-up appointment. Interview conducted on 06/25/13, at 7:00 PM with LPN #6 revealed the LPN assessed the resident's incisions on 05/22/13, 05/23/13, 05/27/13, 05/31/13, 06/01/13, 06/02/13, 06/05/13, and 06/06/13. The interview revealed the incision was slightly red upon admission and increased in redness during the stay; however, LPN #6 stated she had not documented the assessment and failed to notify the resident's family member or the resident's physician of the change in the resident's surgical incision. Interviews conducted on 06/25/13, at 5:50 PM with the Director of Nursing (DON) and Registered Nurse (RN) #2 confirmed the facility's policy was to notify the resident's physician of changes in a resident's condition. The interview revealed the nurses were to assess Resident #1's incisions daily and document the assessment on the TAR. However, the DON and RN #2 acknowledged facility staff had failed to always document the assessment of Resident #1's surgical incisions, including a description of the appearance of the wounds, as required by facility policy and confirmed there was no family member or physician notification of any changes in the resident's surgical incisions.

Based on interview, closed medical record, and incident/accident review, it was determined the facility failed to ensure services were provided to one of three sampled residents (Resident #1) in accordance with the resident's written plan of care. Based on the facility's assessment, Resident #1 required the assistance of two staff persons for bedpan use and bed mobility. However, on [DATE], one State Registered Nursing Assistant (SRNA) attempted to assist Resident #1 from a bedpan and the resident fell from the bed. As a result of the fall, the resident sustained [REDACTED]. Resident #1 was transferred to the hospital on [DATE], and diagnosed with [REDACTED]. The resident expired on [DATE], from a possible [MEDICAL CONDITION] embolism. The findings include: Interview with the Director of Nursing (DON) on [DATE], at 10:50 AM, revealed the facility did not have a policy related to resident care plans. A review of the incident/accident report revealed on [DATE], Resident #1 rolled over in bed to allow SRNA #6 to remove a bedpan and fell from the bed. The incident/accident report further revealed staff observed a laceration to the left side of Resident #1's head and a hematoma (a collection of blood outside the blood vessel) on the left side of the resident's face. A review of the written Witness Statement from SRNA #6, dated [DATE], revealed Resident #1 "had her light on I went in to see what she wanted, she wanted off the bedpan. She rolled over for me to dry her and she rolled too far. I tried to catch her but I could not." A review of the closed medical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment completed on [DATE], revealed facility staff had assessed Resident #1 as a 12. According to the assessment, a total score of greater than 10 indicated the resident was a high risk for falls. A review of a Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed facility staff had assessed Resident #1 to require extensive assistance of two staff persons for bed mobility and bedpan use. A review of Resident #1's care plan, dated [DATE], revealed facility staff assessed Resident #1 to require "limited" to "total" assistance with activities of daily living (ADL) due to a history of [MEDICAL CONDITION] (Stroke) with left sided [MEDICAL CONDITION] (weakness on left side of body). A review of interventions revealed staff was required to assist the resident to turn/reposition at least every two hours, assist with peri-care every shift, and to provide assistance with bedpan for toileting needs at the resident's request. A review of the Nurse Aide Care Plan (NACP) for [DATE] revealed facility staff assessed Resident #1 to require the assistance of two staff members for bed mobility and bedpan use. Interview on [DATE], at 2:45 PM, with SRNA #6, who assisted Resident #1 on [DATE], revealed she went into Resident #1's room to assist the resident off the bedpan. The SRNA stated she asked Resident #1 to roll over to allow the bedpan to be removed, the resident rolled too far, and fell off the bed. SRNA #6 stated she tried to catch the resident but could not get to the resident quick enough to prevent the fall. SRNA #6 stated she reviewed each resident's NACP two to three times a week. However, the SRNA stated she "didn't look closely" when she looked at Resident #1's NACP and was not aware Resident #1 required the assistance of two staff members for bed mobility and bedpan use, or that the resident was a fall risk. Interviews conducted on [DATE], with SRNA #4 at 12:05 PM, SRNA #5 at 12:15 PM, and Licensed Practical Nurse (LPN) #1 at 2:30 PM, revealed staff was required to look at care plans (CPs) to determine each resident's required level of care. SRNA #4 stated staff was required to look at the CP one time a week. SRNA #5 stated CPs were to be looked at every day, and LPN #1 stated the CP was to be looked at two to three times a week. Interview further revealed SRNA #4, SRNA #5, and LPN #1 thought one staff member could assist Resident #1 with the bedpan because the resident could provide assistance with turns by using the side rails. LPN #1, CNA #4, and CNA #5 stated they were not aware Resident #1 had been assessed to require the assistance of two staff members for bed mobility and bedpan use, and were not aware Resident #1 had been assessed as a fall risk. Interview with Registered Nurse (RN) #1 on [DATE], at 10:30 AM, revealed nurses were responsible to update the Comprehensive Care Plan (CCP) and the NACP with any new orders or changes in care for each resident. RN #1 further stated she was aware Resident #1 required the assistance of two staff members for bed mobility and bedpan use. RN #1 stated when she became aware only one staff member had assisted Resident #1 on [DATE], the day of the fall, she informed the Unit Manager (UM), and the NA Coordinator "a couple of days later." Interview with the Director of Nursing (DON) on [DATE], at 4:15 PM, revealed staff was required to check the Care Plans on a daily basis.

Based on interview, closed record review, the facility's incident/accident report, and hospital records, it was determined the facility failed to ensure one of three sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. Facility staff assessed Resident #1 to be at high risk for falls, and required the assistance of two staff persons for bed mobility and bedpan use. The facility failed to have an effective system to ensure assistance was provided to prevent accident/injuries to Resident #1. On [DATE], one staff person attempted to assist Resident #1 to roll over in bed to remove a bedpan, and Resident #1 fell from the bed sustained a laceration to the head and a left hip fracture. On [DATE], Resident #1 was transferred to the hospital and assessed to have a laceration and hematoma to the left side of face and scalp, which measured 5.0 cm (centimeters), and an acute, mildly displaced left subtrochanteric fracture (left hip fracture). Further review of Resident #1's hospital record revealed the resident was transferred to another hospital to undergo surgery to correct the hip fracture on [DATE], and expired on [DATE], from a possible pulmonary embolism. The findings include: Interview with the Director of Nursing (DON) on [DATE], at 4:15 PM, revealed the facility did not have a policy related to falls or accidents. A review of the incident/accident report dated [DATE], revealed staff attempted to assist Resident #1 from a bedpan, the resident rolled over to the side, and fell from the bed. Documentation revealed staff observed a laceration to the left side of the resident's head and a hematoma on the left side of the resident's face. The incident/accident report further revealed one staff person had assisted the resident at the time of the incident. A review of the facility Witness Statement Form, dated [DATE], written by State Registered Nurse Aide (SRNA) #6, revealed the SRNA responded to Resident #1's call light and the resident requested assistance off a bedpan. Documentation revealed Resident #1 rolled over to allow SRNA #6 to provide incontinence care, and the resident fell from the bed. The witness statement revealed SRNA #6 was unable to prevent the resident's fall. A review of the closed medical record revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed facility staff assessed Resident #1 to require extensive assistance of two staff persons for all bed mobility and bedpan use. A review of the Fall Risk assessment dated [DATE], revealed facility staff assessed Resident #1 to be at high risk for falls. Based on the assessment, a score of 10 and above indicated a resident was a high risk for falls. Staff assessed Resident #1 as a 12 on the assessment. A review of Resident #1's Care Plan (CP) dated [DATE], revealed the facility identified Resident #1 at risk for falls and/or injury due to an unsteady gait when assisted with transfers, [DIAGNOSES REDACTED]. A goal on the care plan was for Resident #1 to experience no injuries related to falls. The facility's planned approach to the goal included to assess the resident for safety, to use a bed with a high/low position, and two side rails. A review of the Nurse Aide Care Plan (NACP) for [DATE] revealed Resident #1 required the assistance of two staff persons for bed mobility and bedpan use. A review of the Post Fall Analysis completed by the SRNA Supervisor (who is also the Risk Manager for falls), dated [DATE], revealed the resident rolled out of the bed on [DATE], while receiving care. The analysis revealed SRNA #6 was assisting Resident #1 from the bedpan, the resident rolled over, and fell from the bed. The report indicated the resident preferred for the bed to be in a high position at all times and refused for side rails to be raised. The Post Fall Analysis also revealed SRNA #6 attempted to stop the resident but failed to prevent the fall. Interview with SRNA #6 on [DATE], at 2:48 PM, revealed on [DATE], she responded to Resident #1's request to be taken off the bed pan. The SRNA stated she asked the resident to roll over and when the resident rolled over the resident rolled too far and fell from the bed. SRNA #6 stated that she was not aware Resident #1 had been assessed to require the assistance of two staff members for bed mobility and bedpan use or that the resident was a fall risk. The SRNA stated one staff member provided care for Resident #1 on a daily basis. Interview on [DATE], at 12:05 PM, 12:15 PM, and 2:30 PM, with SRNAs #4 and #5, and Licensed Practical Nurse (LPN) #1, revealed the daily care provided to each resident was based on each resident's written CP. Interview further revealed SRNA #4, SRNA #5, and LPN #1 thought one staff member could assist Resident #1 with the bedpan because the resident could provide assistance with turns by using the side rails. LPN #1, CNA #4, and CNA #5 stated they were not aware Resident #1 had been assessed to require the assistance of two staff members for bed mobility and bedpan use, and were not aware Resident #1 had been assessed as a fall risk. However, review of the Nurse Aide Care Plan (NACP) for [DATE] revealed Resident #1 required the assistance of two staff persons for bed mobility and bedpan use. Interview with the DON on [DATE], at 4:15 PM, revealed the facility did not have a system in place to ensure CNAs reviewed the nurse aide care plan as required. Further interview with the DON on [DATE], at 4:15 PM, and the House Supervisor on [DATE], at 6:00 PM, revealed even though the facility did not have a falls/accident policy, if a resident sustained [REDACTED]. However, according to interviews, the facility did not monitor interventions related to falls and assumed the interventions were effective if the resident sustained [REDACTED].