Every finding on record at Buchanan Place

Based on facility policy review, medical record review, and interview, the facility failed to submit a Pre-admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis for 2 residents (Resident #4 and Resident #79) of 11 residents reviewed for PASRR.The findings include: Review of the facility's PASRR (Preadmission Screening and Resident Review) Policy, undated, revealed .The facility shall ensure .Timely identification of residents requiring Resident Review due to significant changes in status .Level I Screening .Initial screening performed prior to admission or when a significant change in status occurs . Review of a Level 1 PASRR dated 6/30/2025 (prior to admission), revealed Resident #4 had diagnoses of Anxiety Disorder and Mild or Situational Depression. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder and Major Depressive Disorder. Continued review revealed the resident received a new mental health diagnosis of Psychotic Disorder with Delusions on 7/4/2025. Review of the comprehensive care plan revised 5/13/2026, revealed Resident #4 had a care plan for Major Depressive Disorder, Anxiety Disorder, and Psychotic/Delusional Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had active diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. Review of the medical record revealed a new PASRR for Resident #4 had not been submitted for the new diagnoses of Major Depressive Disorder and Psychotic Disorder with Delusions. Review of a Level I PASRR dated 7/27/2021 (prior to admission), revealed Resident #79 had diagnoses of Schizophrenia, Schizoaffective Disorder, Major Depression, Psychotic/Delusional Disorder, Bipolar Disorder, Personality Disorder, Anxiety Disorder, Mild or Situational Depression, and Other Mental Health Diagnosis (Malingerer). Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with a diagnosis of Post Traumatic Stress Disorder (PTSD). Review of the comprehensive care plan revised 1/21/2025, revealed Resident #79 had a care plan for PTSD. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #79 had an active diagnosis of PTSD. Review of the medical record revealed a new PASRR for Resident #79 had not been submitted for the diagnosis of PTSD. During an interview on 6/23/2026 at 1:51 PM, the Director of Nursing (DON) stated a new Level I PASRR should be submitted with any new major mental health diagnosis. The DON confirmed that Resident #4 and Resident #79 did not have a new Level I PASRR submitted after a new mental health diagnosis was identified.

Based on facility policy review, medical record review, observations and interviews, the facility failed to obtain a Physician's Order for 1 resident (Resident #26) of 2 residents reviewed for Continuous Positive Airway Pressure (C-PAP) use. The findings include: Review of the facility's policy titled, Physician Services, dated 4/2013, revealed .Physician orders .shall be maintained in accordance with current .regulations and facility policy . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses to include Obstructive Sleep Apnea and Shortness of Breath. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a diagnosis of Obstructive Sleep Apnea. Review of the Physician Orders dated 6/23/2026, revealed Resident #26 did not have an order for the use of a C-PAP machine.During an observation and interview on 6/23/2026 at 10:53 AM, in Resident #26's room, revealed the C-PAP machine on the bedside nightstand. Further interview revealed the resident had used a C-PAP for over 15 years and had admitted to the facility with the C-PAP. During an observation on 6/23/2026 at 11:15 AM, in Resident #26's room, revealed Resident #26 sitting in his wheelchair at bedside. On the bedside nightstand a C-PAP machine was observed. During an observation on 6/23/2026 at 1:14 PM, in Resident #26's room, revealed on the bedside nightstand a C-PAP machine was observed. During an interview on 6/23/2026 at 1:17 PM, Licensed Practical Nurse (LPN) A confirmed Resident #26 did not have an order for the use of a C-PAP machine. During an observation and interview on 6/23/2026 at 1:44 PM, The Assistant Director of Nursing confirmed Resident #26 did not have a physician's order for the use of a C-PAP machine.

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 4 residents (Residents #75, # 74, #78, and #6) in 1 of 2 dining areas observed for meal tray distribution, and failed to ensure C-PAP equipment was kept in a clean and sanitary condition for 1 resident (Resident #26) of 2 residents reviewed for C-PAP. The Findings include: Review of the facility's policy titled, Assisting the Resident with In-Room Meals, revised 12/2013, revealed .Employees must wash their hands before serving food to residents .employee must wash his/her hands before serving food to the next resident . Review of the facility's policy titled, Hand Washing, revised 5/17/2016, revealed .The facility considers hand hygiene .primary means to prevent .spread of infections . Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus (DM), and Depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #75 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #75 required Setup or clean-up assistance with eating and partial/moderate assistance with Activities of Daily Living (ADLs). Review of the comprehensive care plan dated 5/24/2026, revealed Resident #75 .Requires assistance with ADLs r/t [related to] self-care deficit .d/t [due to] .DM COPD . During an observation on 6/22/2026 at 12:07 PM, the Activities Director (AD) delivered the lunch meal tray to Resident #75. The AD set up the meal tray for Resident #75 and failed to offer the resident hand hygiene and the AD failed to sanitize her hands after serving the tray. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Diabetes Mellitus, Dementia, and Need for Assistance with Personal Care. Review of the quarterly MDS assessment dated [DATE], revealed Resident #74 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required supervision or touching assistance with eating and partial/moderate assistance with ADLS. Review of the comprehensive care plan dated 5/18/2026, revealed Resident #74 .Requires assistance with ADL's .impaired cognition .need for assistance with personal care .Staff to assist with completion of ADL's on .daily basis . During an observation on 6/22/2026 at 12:10 PM, the AD delivered the lunch meal tray to Resident #74. The AD set up the tray for Resident #74 and failed to offer hand hygiene to the resident and the AD failed to sanitize her hands after serving the tray. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #78 required supervision or touching assistance with eating and partial/moderate assistance with personal hygiene. Review of the comprehensive care plan for Resident #78, dated 6/10/2026, revealed .Requires assistance with ADL's r/t .self care deficit .d/t .Dementia .COPD . During an observation on 6/22/2026 at 12:11 PM, AD delivered the lunch meal tray to Resident #78. AD set up tray for Resident #78 and failed to offer hand hygiene for the resident before assisting with the lunch meal and AD failed to sanitize her hands after serving the tray. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Anxiety, Depression, and Need for Assistance with Personal Care. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #6 required supervision or touching assistance with eating and dependent with personal hygiene. Review of the comprehensive care plan for Resident #6, dated 4/30/2026, revealed .Requires assistance with ADL's r/t self-care deficit .staff to assist with completion of ADL's on a daily basis . During an observation on 6/22/2026 at 12:13 PM, the AD delivered the lunch meal tray to Resident #6. The AD set up tray for Resident #6 and failed to offer hand hygiene for the resident before assisting with the lunch meal and the AD failed to sanitize her hands after serving the tray. During an interview on 6/22/2026 at 12:15 PM, the AD confirmed that she had not offered hand hygiene while passing the meal service trays to Residents #75, #74, #78, and #6 and had failed to sanitize her hands after passing the lunch meal trays to Residents #75, #74, #78, and #6. During an interview on 6/23/2026 at 2:44 PM the Infection Preventionist (IP) confirmed that it was her expectation that staff offer hand hygiene to residents when serving meal trays, and that staff sanitize hands between each meal tray. During an interview on 6/24/2026 at 8:28 AM, the Director of Nursing (DON) stated it was the facility's expectations hand hygiene was to be offered to residents prior to meals and staff sanitize hands after passing each resident's meal tray. Review of the facility's policy titled, CPAP/BIPAP, [continuous positive airway pressure/bilevel positive airway pressure] dated 3/2026, revealed .Each resident receives necessary care and services .in accordance with professional standards of practice . Review of the facility's policy titled, CPAP/BIPAP Support/Maintenance, dated 3/2015, revealed .General Guidelines for Cleaning .Masks .and tubing .Clean daily by placing in warm, soapy water and soaking for 5 minutes .Rinse with warm water .air dry . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Obstructive Sleep Apnea and Shortness of Breath. Review of a quarterly MDS assessment dated [DATE], revealed Resident #26 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident had a diagnosis of Obstructive Sleep Apnea. During an observation and interview on 6/23/2026 at 10:53 AM, in Resident #26's room, revealed a C-PAP machine positioned on the nightstand. The C-PAP tubing and mask were resting on the mattress of the bed. The mask had a brown substance caked on the inside of the mask. The resident stated he did not know when the mask had last been cleaned. Further interview revealed the resident had used a C-PAP for over 15 years and had admitted to the facility with the C-PAP. During an observation on 6/23/2026 at 11:15 AM, in Resident #26's room, revealed Resident #26 sitting in his wheelchair at bedside. On the nightstand was a C-PAP machine with the tubing under a pillow and mask exposed on the mattress. The inside lining of the mask was caked with a brown substance. During an observation on 6/23/2026 at 1:14 PM, in Resident #26's room, revealed a C-PAP on the bedside nightstand. The tubing and mask were resting on the mattress of the bed. The mask had a brown substance caked on the inside of the mask. During an interview on 6/23/2026 at 1:17 PM, in Resident #26's room. Licensed Practical Nurse (LPN) A, confirmed the mask was dirty with a brown substance and could not indicate when the mask was last cleaned. During an observation and interview on 6/23/2026 at 1:44 PM, in Resident #26's room, The Assistant Director of Nursing (ADON) confirmed the C-PAP mask was dirty and had a caked on brown substance on the inside of the mask and stated, .the mask definitely needs to be cleaned . The ADON confirmed the expectation was for the C-PAP mask to be clean, sanitary, and free of debris for resident use.

Based on facility policy review, facility investigation documentation review, medical record review, observations, and interviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 resident (Resident #15) of 22 residents reviewed for abuse. Resident #17 struck Resident #15 on 4/20/2025 and again on 5/7/2025. The findings include: Review of the facility policy titled, Freedom from Abuse and Neglect Policy, not dated, revealed .each resident has the right to be free from abuse. Abuse includes, verbal, mental, physical . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of a quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #15 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated resident is cognitively intact. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Aphasia, Cognitive Communication Deficit, Chronic Kidney Disease, and non-Hodgkin lymphoma. Review of a quarterly MDS assessment dated [DATE], revealed Resident #17 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Review of a Nursing Progress Note for Resident #17 dated 4/20/2025, revealed .called to room .observed CNA (certified nursing assistant) removing resident (Resident #17) from room .Resident (Resident #15) stated she hit me three times in the left arm .This nurse .called Abuse Coordinator . Review of a Nursing Progress Note dated 4/20/2025, revealed .called on call physician .seen both residents (Resident #15 and #17) via video call. New order for Resident (Resident #17) to be 1 on 1 x 24 hours . Review of a skin assessment for Resident #15 dated 4/20/2025, revealed .slight redness above ac (antecubital) during assessment . Review of the comprehensive Care Plan for Resident #15 revised 4/21/2025, revealed, .stop sign to door-assist resident as needed to keep stop sign on door in place . Review of a Nursing Progress Note for Resident #17 dated 5/7/2025, revealed .Nurse .reported that she was at the nursing station when heard yelling on .hall .she observed (Resident #17) exiting another resident's room. Residents were immediately separated and assessed .skin assessments completed with no issues noted .resident placed one on one with staff while up in chair . Review of the facility investigation dated 5/7/2025, at 4:35 PM revealed .nurse reported she was at nurse's station when she heard yelling on B hall. As she was going down B hall, she observed another resident exiting [Resident #15] room. When asked what happened, [Resident #15] said she asked the other resident [Resident #17] to leave, and she began hitting her .residents separated immediately. Skin assessment completed .redness noted to left upper breast and left index finger knuckle. No open areas or swelling noted. Resident denies pain .No injuries noted at time of incident . Review of a skin assessment for Resident #15 dated 5/7/2025, at 8:54 PM revealed no areas of concern documented. Review of an .Employee Warning Form . dated 5/8/2025, revealed employee violation .did not attach stop sign across doorway after returning the resident from an appointment .To avoid further disciplinary action, employee should: Review cardex to ensure that we are following the care plans for each resident . Review of a facility QAPI (quality assurance and performance improvement) meeting dated 5/8/2025, revealed agenda .abuse, resident rights, cardex review-following care plans .stop sign monitoring daily 5x (times) /week for 4 weeks . Review of a social services progress note dated 5/8/2025, revealed SW [social worker] spoke with resident [Resident #17] spouse and son .about room change .was agreeable . During an interview with the facility Scheduler on 4/13/2026 at 2:16PM, the Scheduler stated the stop sign was an intervention put in place after the first incident between [Resident #15 and Resident #17]. Continued interview revealed the Schedular did receive the written education after not re-attaching the stop sign after bringing back [Resident #15] from an appointment. During a phone interview with Licensed Practical Nurse (LPN) D on 4/13/2026 at 4:37 PM, LPN D stated he completed the skin assessment on Resident #15 in the evening of 5/7/2025. Continued interview revealed Resident #15 had no signs of injury or bruising after the resident-to-resident contact as the 5/7/2025 skin assessment stated. During an observation on 4/14/2026 at 8:24 AM, revealed the stop sign outside Resident #15 room not in place. Continued observation revealed no staff observed in sight of room with Resident #15 sitting on side of bed. During an interview with Resident #15 on 4/14/2026 at 8:25 AM, the Resident stated Resident #17 did come into her room on two separate occasions when she was located across the hallway and struck her. Continued interview revealed Resident #15 stated .she didn't hurt me .no other concerns since .she's not the same person now . Further interview revealed Resident #15 stated .they [facility staff] don't keep the stop sign up much now . During an observation and interview with LPN A on 4/14/2026 at 8:27 AM, the LPN stated the stop sign was supposed to be in place .that's my fault . Continued interview revealed the LPN forgot to put the stop sign back up after exiting Resident #15's room. During an interview and medical record review on 4/14/2026 at 8:40 AM, the Director of Nursing (DON) stated Residents #15 and #17 had no further resident to resident altercations or any lasting effects with facility follow up by social services. Continued interview and medical record review confirmed the DON expected the stop sign to be in place for Resident #15. During an interview on 4/15/2026 at 9:15 AM, the DON confirmed physical contact did take place between Resident #15 and Resident #17, when Resident #17 struck Resident #15 on 4/20/2025 and 5/7/2025, and neither resident sustained any injuries.

Based on facility policy review, medical record review, and interviews, the facility failed to implement the comprehensive care plan for 1 resident (Resident #15) for 22 residents reviewed for care plans.The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed .A comprehensive, person- centered care plan that includes measurable objectives .to meet the resident's physical, psychosocial and functional needs .the care plan interventions are derived from a thorough analysis of the information gathered . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of a quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #15 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated resident is cognitively intact. Review of the comprehensive Care Plan for Resident #15 revised 4/21/2025, revealed, .stop sign to door-assist resident as needed to keep stop sign on door in place . During an observation on 4/14/2026 at 8:24 AM, revealed the stop sign outside Resident #15 room not in place. Continued observation revealed no staff observed in sight of room with Resident #15 sitting on side of bed. During an interview with Resident #15 on 4/14/2026 at 8:25 AM, the Resident stated .they [facility staff] don't keep the stop sign up much now . During an observation and interview with LPN A on 4/14/2026 at 8:27 AM, the LPN stated the stop sign was supposed to be in place .that's my fault . Continued interview revealed the LPN forgot to put the stop sign back up after exiting Resident #15's room. During an interview and medical record review on 4/14/2026 at 8:40 AM, the Director of Nursing (DON) confirmed Resident #15's care plan intervention was not followed. Continued interview revealed the DON stated she expected the stop sign to be in place for Resident #15's door.

Based on facility policy review, medical record review, facility documentation review, observation and interviews, revealed the facility failed to ensure 1 resident (Resident #6) received adequate supervision to prevent elopement (a situation which involves a resident leaving the premises or safe area without necessary supervision) from the premises of 7 sampled residents reviewed for accidents. On 6/18/2024, at approximately 4:15 PM, the facility staff were unable to locate Resident #6. The resident remained out of staff supervision for 1 hour and 12 minutes. The facility's failure to provide adequate supervision placed Resident #6 and 20 other residents, identified as having the potential for elopement, at risk for Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operation (VPCO) were notified of the Immediate Jeopardy on 5/10/2024 at 10:45 AM in her office. The facility was cited Immediate Jeopardy at F-689. The facility was cited Immediate Jeopardy (IJ) at F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ began on 6/18/2023 and continued through 6/22/2023. The facility's corrective actions were completed on 6/22/2023. An acceptable Allegation of Compliance for the past non-compliance, which removed the immediacy, was provided by the facility on 5/10/2024 and was validated on site. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy, Elopement Management Program, dated 12/26/2016 revealed .A system that addresses a resident's risk of elopement from the premises or safe area without authorization and/or necessary supervision to do so . Medical record review revealed Resident #6 was admitted to the facility's secure unit on 6/16/2023 with diagnoses including Pneumonia, Dementia, and Delusional Disorders. Review of an Elopement Risk assessment dated [DATE], revealed Resident #6 was assessed to be at risk for elopement due to his Dementia, comments about wanting to go home and exit-seeking behaviors. Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed Resident #6 scored a 2, which indicated the resident had severe cognitive impairment. Review of the facility documentation dated 6/18/2023, showed Resident #6 exited the secure unit at approximately 3:30 PM, by following a visitor out the secure unit door. The resident walked down the hallway and the front door camera showed the resident followed a group of visitors out the main entrance doors on 6/18/2023 at 3:37 PM. Continued review revealed Resident #6's son entered the facility and was unable to locate the resident. The facility staff were notified and searched the secure unit. When Resident #6 was unable to be located, a Code Pink (all staff conduct a head count of their residents and search for the missing resident throughout the facility) was initiated. Further review revealed a Certified Nursing Assistant (CNA) D drove her car and looked for the resident. Resident #6 was located at a gas station 1.1 miles away from the facility. The resident returned to the facility with CNA D in her car at approximately 4:15 PM. The resident was assessed for injury, none noted, and was placed with 1:1 supervision. Review of a nurse's note dated 6/18/2023, revealed the physician had ordered Resident #6 be placed with 1:1 supervision post elopement. During an interview on 5/7/2024 at 10:00 AM, Licensed Practical Nurse (LPN) B stated she was not working the day Resident #6 eloped from the facility. Continued interview revealed, after she returned to work the following day, Resident #6 received 1:1 supervision and all the codes to the keypads in the facility were changed. LPN B stated the staff was not allowed to give the codes to anyone except for Emergency Services Technicians. During a telephone interview on 5/9/2024 at 8:45 AM, CNA C confirmed she was working the day Resident #6 eloped from the facility and thought he must have followed a family member out of the secure unit. Continued interview revealed before the elopement, family members were allowed to have the access codes for the keypads. During an interview on 5/9/2024 at 1:15 PM, the DON and the Assistant Director of Nursing (ADON) revealed they had watched the camera footage which showed a time stamp of 3:37 PM, when Resident #6 exited through the main entrance doors. The resident was located and returned to the facility at 4:45 PM (approximately 1 hour and 12 minutes) after he eloped. During a telephone interview on 5/10/2024 at 8:30 AM, CNA D revealed Resident #6's son asked her if she knew where his father was and the CNA checked his room and the shower. The CNA then reported to her co-workers Resident #6 could not be located and they searched the secure unit. The CNA stated the nurse called a Code Pink and CNA D got in her car, drove around a housing development across the street and continued down the road. Continued interview revealed she saw the resident standing in the parking lot of a gas station and asked the resident if he would like something to drink, he said yes, got into the car with her, and she drove him back to the facility. The facility's corrective actions for the removal plan were issued to the surveyor on 5/10/2024. The corrective action plan included the following: 1. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility held a Quality Assurance Performance Improvement meeting on 6/18/2023 which determined the root-cause analysis to be Resident #6 had followed a visitor out of the secure unit and then followed another group of visitors out the main entrance doors. The following facility staff members attended the QA meeting: Administrator, DON, Nurse Consultant, Assistant Director of Nursing, Unit Managers, Activities Director, Business Office Manager, and the Medical Director by phone. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/18/2023-6/19/2023, all residents were reassessed for elopement risk by the Director of the Secure Unit, ADON, and Unit Manager (UM). There were 20 residents at risk for elopement with no new residents identified. On 6/18/2023, all the doors in the facility were checked to ensure they were locked, secure, and functioning properly by the Maintenance Director. There were no concerns identified. On 6/19/2023, the facility conducted a 30-day look back of nurses' notes, the electronic medical record, and the 24-hour report log to identify residents for exit seeking behaviors, wandering or comments of wanting to leave the facility. A review of the elopement binders, located at each nursing station, was completed by the Nurse Consultant, DON, ADON, and UM. On 6/19/2023, facility Administrator, DON, UM, ADON, Social Services Director, Admissions Director, Dietary Manager, Minimum Data Set (MDS) Coordinators, Maintenance Director, Business Office Manager, Director of Care Coordination, Rehabilitation Manager, Dietary Manager, and Activities Director were educated by the facility's Nurse Consultant on policies, procedures, and processes. The training included: Elopement, Missing Resident, Door codes/alarms, Accident/Incident, Safety and Supervision, Implementation of Interventions and Resident Rights. The training was performed face to face to facilitate discussion and questions. Department administrative managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If a manager did not score 100% on the post-test, the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Nurse Consultant. Continued education was conducted either in person or by phone with all other staff, completed 6/22/2023. If a staff member was not available to attend the education, they were to be provided the education prior to their next shift worked. The process was monitored by each department head. 3. What measures will be put into place or systemic changes to ensure the deficient practice will not reoccur? On 6/19/2023, the facility conducted a Code Pink drill daily on both shifts and continued to do so for 1 week. The drills continued for 4 weeks and then quarterly on various shifts and days. The facility implemented Guardian Rounds (walking rounds with visual observations done throughout the facility, observing for an increase in behaviors/wandering/exit seeking for residents) to be completed daily by department managers and the Manager on Duty for the weekends. The Removal Plan was validated onsite by the surveyor on 5/10/2024, which included review of the facility documentation to show each step had been completed and facility staff interviews. 1. Progress notes showed Resident #6 was discharged to a Psychiatric hospital on 8/8/2023 and did not return to the facility. 2. Review of a QAPI meeting sign-in sheet dated 6/18/2023 and interview with the DON/ADON confirmed the facility met and completed a root cause analysis. 3. Review of a facility document dated 6/18/2023 and interview with the Maintenance Director confirmed he checks all the doors daily for functionality and the doors are checked on weekend by the assigned department head designated as the Weekend Manager. 4. Review of the documentation of the drills and interviews with the Maintenance Director and Administrator confirmed the drills were ongoing and were being reviewed in the QAPI meetings. 5. Review of a census roster dated 6/18/2023 with the title Elopement Risk Evaluations written on the top of the document and interview with the DON/ADON confirmed the elopement assessments for all residents were completed by 6/19/2023. 6. Review of handwritten statements dated 6/18/2023-6/19/2023 and interview with the DON/ADON confirmed the 30-day look back was completed for all residents with no unidentified concerns. 7. Review of a sign-in sheet along with a copy of all policies, procedures, processes, and interviews completed throughout the complaint survey conducted on 5/6/2024-5/10/2024 revealed all staff were aware of the elopement management, Code Pink, where to find the elopement risk binders, and they were not to give the access codes to anyone, other than a co-worker to the facility doors. Interviews conducted on 5/10/2024 with 2 nurses and 3 CNAs assigned to the secure unit, confirmed the staff were aware of the location of the elopement binders, what to do for a Code Pink, and the keypad codes were not given to family members.

Based on review of facility policies, medical record reviews, review of facility investigations and interviews, the facility failed to maintain controls (chain of custody) on narcotic inventories which resulted in diversion of narcotic stocks for 3 of 20 residents (Residents #4, #9, and #35) of 20 residents sampled for misappropriation, of 35 sampled residents. The findings include: Review of the facility's, Medication Disposal and Returns Policy, effective 6/21/2017, showed .Nursing staff is responsible for removing all discontinued medications from the cart and/or storage areas. Full chain of custody should be documented to clearly indicate the removal of the medication from the cart and placed into a secure storage area for destruction .Two individuals .shall witness and document the destruction in the format required per the applicable state regulations .follow State Regulations regarding the timing of the destruction .Controlled substances not authorized by the physician for release to the resident at the time of discharge are to be destroyed . Review of the facility policy, Controlled Substances, Administration of Schedule 2 Controlled Medications, effective 6/21/2017, showed, .Administration of Scheduled Controlled Substances will be consistent with the policies for general medication administration with the additional requirement of logging all doses on the individual residents [Controlled Drug Receipt/Record/Disposition Form] All scheduled controlled medications removed from storage .will be entered onto the individual Resident's Controlled Drug Receipt/Record/Disposition Form .Any Discrepancies .must be immediately reported to the Director of Nursing .The facility shall maintain a record and signed scheduled medication count at each change of shift .by on-coming nurse .with off-going nurse .using facility approved form .Any discrepancies in the [ shift count] must be immediately reported to the Director of Nursing for further action . Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Presence of Right Artificial Hip Joint, Adult Failure to Thrive, Unspecified Psychosis, Chronic Obstructive Pulmonary Disease and Generalized Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #4 had a Brief Interview of Mental Status Score of 0/15, which indicated Resident #4 was severely cognitively impaired. Resident #4 had impaired thought processes, symptoms of delirium and was dependent upon one or two persons for all activities of daily living. Review of Physician Orders and the December 2023 Medication Administration Records showed Resident #4 was prescribed Morphine Oral Solution (a narcotic) 10 milligrams (mg) per 0.5 milliliters (ml) every 2 hours as needed for pain. Review of the facility investigation showed on 12/21/2023 Licensed Practical Nurse D (oncoming nurse) assumed care of Resident #4 after completion of the shift change medication cart narcotic reconciliation process around 6:00 PM. LPN D counted the narcotic inventories and signed off that all narcotic inventories were correct with LPN E, (the off-going nurse). Continued review showed around 9:00 PM (3 hours later) LPN D became suspicious the narcotic count previously performed was not accurate and asked another nurse (Registered Nurse, RN B) to recheck the narcotic inventories on the cart with attention to morphine supplies on hand for Resident #4, at which time, it was discovered the morphine inventory was actually 7.5 ml short (equal to 35 mg of morphine) of what was documented to be on hand. LPN D notified the Director of Nursing who verified the morphine supply documented on the facility Narcotic Reconciliation Forms was inaccurate and launched an investigation. Continued review of the facility investigation and witness statements revealed the following: -LPN E did not contact the facility for 7 days during the investigation, despite multiple attempts to reach her, and when eventually contacted, categorically denied misappropriation of the missing morphine and noted LPN D had counted the medication at shift change on 12/21/2023 and signed documentation that the count was correct at that time. -LPN D denied misappropriation and reported at that time during the shift count with LPN E, she expressed concerns to LPN E, the morphine inventory for Resident #4 appeared short but was assured by LPN E it was accurate and appeared short due to LPN E's failure to document missing doses given that morning, which LPN E reported to LPN D she would immediately correct. -LPN D did not stop the count, and report irregularities to the Director of Nursing at once. -LPN D discovered 3 hours later, LPN E had made no changes to the facility Narcotic Reconciliation Logs as she had promised, and there was no documentation of morphine administration to Resident #4 in the electronic records that day (MAR), during LPN E's shift, then reported the irregularity to the DON. -LPN E denied she made such statements to LPN D and categorically denied wrongdoing. Continued review of the investigation showed the missing morphine was never recovered, nor could the facility accurately identify when the missing morphine was misappropriated, or by whom and neither employee involved in the 12/21/2023 incident underwent drug testing in response to the incident. Medical record review showed Resident #9 was admitted to the facility on [DATE] with diagnoses including Presence of Left Artificial Hip Joint, Sacral Osteomyelitis, Left Hip Pain and Disruption of Surgical Wound. Review of the quarterly MDS dated [DATE], showed Resident #9 with a BIMS of 13/15 which indicated the resident was cognitively intact. Resident #9 required assistance of one or two persons for ADLs. Review of Resident #9's medical record showed he was discharged from the facility 3/2023. Medical record review showed Resident #35 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Left Femur Fracture, Encounter for Surgical Aftercare of the Digestive System, Chronic Pain, Unspecified Dementia and Sepsis. Review of the quarterly MDS dated [DATE], showed Resident #35 had a BIMS of 13/15 which indicated the resident was cognitively intact. Resident #35 required assistance of one person for activities of daily living. Review of the facility investigation dated 3/27/2023, showed on that date, the following: -The facility was contacted by a former employee who had left employment with the facility in 1/2022. -The former employee informed the facility she was landlord to a current employee (CNA B). -The former employee reported she had evicted CNA B from the property she rented to her and while clearing CNA B's possessions from the property, discovered multiple cards of controlled substances, in their original packaging from the nursing home, for multiple residents, all dated between June 2022 and August 2022. -The former employee reported to the facility she summoned law enforcement to the residence and local police had launched an investigation. -Continued review of the facility investigation and witness statements revealed CNA B categorically denied misappropriation of the medications during interviews with both police and the facility and denied knowledge of how they came to be found on the property she rented from the former employee. -The facility investigation also revealed all medications recovered by police were discontinued medications that had been slated for destruction at the facility when they were diverted, and police had discovered them with their corresponding Controlled Drug Receipt/Record/Disposition Forms attached to the cards. -The facility investigation failed to identify a potential alleged perpetrator (As CNA B had no access to secured areas where drugs were stored pending disposal). -The facility failed to identify how/when the discontinued medications had gone missing in the first place, or how the misappropriation of discontinued narcotics went undetected by the facility or it's pharmacy provider when drugs were destructed. Review of the police report showed, in total, local law enforcement recovered 7 (name of narcotic) 5 mg tablets, 34 (name of nerve pain medication) tablets, 19 (name of benzodiazepine) 2 mg tablets, 19 (name of narcotic) 10 mg tablets, 9 (name of another benzodiazepine) 0.5 mg tablets, and 2 (name of sleeping medication) 5 mg tablets. Local police ruled out the former employee as a suspect, based on dates on the prescriptions, found during their investigation. The former employee had not worked at the facility in the prior 6 months to the time the controlled substances were stolen from the facility and had no access to the facility, residents, or medications. The law enforcement investigation remained open and ongoing at the time of the State Agency Survey. Review of a facility investigation dated 11/18-20/2023, showed the following: -On 11/18/2023, around 10:30 AM, the facility Director of Nursing (DON) observed an on-duty staff member (LPN F) and spoke with her as the DON escorted a group of residents to a local holiday parade. At that time, nothing appeared [NAME]. -Continued review showed around 2:10 PM, upon return to the facility, the DON was informed by the unit manager LPN F was not feeling well and despite offers to be sent home by the unit manager, LPN F had declined. At that time, LPN F reported she had a migraine but showed no signs of impairment and was allowed to remain on-duty. -Continued review showed at 2:51 PM, the DON was informed by floor staff LPN F appeared impaired, with glossy eyes and she was falling over. -The DON was summoned to the floor and removed LPN F from the unit. LPN F struggled to ambulate to the business office without assistance. -At 3:05 PM, LPN F was questioned about substance abuse and denied it. LPN F was advised to submit a urine sample for drug testing. LPN F stated she was unable to provide a sample due to toileting earlier. LPN F was given a soda to drink so she could provide a urine sample. - Shortly after that, LPN F became obtunded, dozed off in the chair, then spilled her drink on herself. -After that, LPN F was aroused by observers, attempted to give a urine sample and was observed as she put water in the urine sample container for testing by observers. -LPN F exhibited hallucinations and stated there was water in the floor not visible to those observing her, her speech became incoherent. She initially refused transportation to a local hospital, citing her lack of health insurance. -The facility attempted to contact LPN F's spouse without success. At 3:55 PM, the DON and Unit Manager transported LPN F to a local hospital by private vehicle for evaluation as LPN F's mental status was obviously altered. LPN F required assistance to be transferred from a private vehicle into the emergency room (ER) and was mentally obtunded to the point she could not give accurate information to ER staff. - LPN F underwent drug testing in the ER where she tested positive for [names of 3 narcotic medication], received 3 doses of [name of the narcotic antagonist to reverse opioid effects on the central nervous system] and was admitted for further treatment. Further review of the facility investigation showed on 11/18/2023, the physician in the ER, informed the facility it appeared LPN F had overdosed on opioids. The facility conducted an audit of narcotic stocks on LPN F's medication cart and discovered multiple discontinued narcotics from a resident, who had passed away the day prior, remained stored on the cart, not disposed of, which included a vial of morphine sulfate 20 mg/ml concentration, which had 4 ml of the medication missing, (equal to 80 mg of morphine) which was unaccounted for on the corresponding Controlled Drug Receipt/Record/Disposition Form. All other medications on the cart were accounted for. During interview on 5/9/2024 at 2:10 PM, the DON confirmed the facility had experienced multiple incidents of narcotic diversion over the prior year, which the facility identified as related to the disposition of discontinued medications, slated for destruction, which were not promptly removed from the medication carts and placed in a designated lock box to await destruction or failure of floor nursing staff to ensure the Controlled Drug counts were accurate at shift change.

Based on facility policy review ,medical record review, facility documentation review and interviews, the facility failed to protect 1 resident (Resident #12) from abuse of 19 residents reviewed for abuse. The findings include: Review of the facility's undated policy titled, Freedom from Abuse and Neglect Policy, revealed .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Types of abuse may include: A. Physical assault or abuse 1. Hitting 2. Slapping .All residents will be protected from harm . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Dementia with Psychotic Disturbance. Review of the comprehensive care plan for Resident #12 dated 4/7/2023, revealed the resident had wandering behaviors. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had severe cognitive impairment. Continued review revealed the resident exhibited physical and verbal behaviors toward others. Review of the Nurse's Note for Resident #12 dated 12/8/2023 at 7:12 AM, revealed .Resident [#12] was witnessed by [Certified Nursing Assistant-CNA B] to be struck multiple times in bilateral [both] arms and right lower jaw by another resident [Resident #21]. CNA B intervened to remove the resident [Resident #12] from the room. Resident [#12] has no visible injuries . The resident was assisted to the dining room where she watched television. Review of the facility document titled, Body Audit (skin assessment) for Resident #12 dated 12/8/2023, revealed the resident had no injuries. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Dementia with unspecified severity, with Other Behavioral Disturbance and Schizoaffective Disorders. Review of the comprehensive care plan for Resident #21 dated 6/8/2023, revealed the resident had aggressive behaviors. Review of a quarterly MDS assessment dated [DATE], revealed Resident #21 was moderately cognitively impaired. Continued review revealed the resident exhibited physical and verbal behaviors toward others . Review of a Nurse's Note for Resident #21 dated 12/8/2023, at 7:04 AM, revealed .Resident [#21] was witnessed by CNA B to strike another resident multiple times in bilateral arms. She also struck the other resident in the lower jaw. [CNA B] intervened to remove the other resident [Resident #12] from the room and the resident [#21] proceeded to try and strike [CNA B] .Notified [Unit Manager] my immediate supervisor of the situation, Assesed [assessed] the resident [#21] she is in her room . Review of the facility document titled, Body Audit for Resident #21 dated 12/8/2023, revealed the resident had no injuries. During an interview on 5/7/2024 at 3:57 PM, CNA B stated she heard a noise coming from Resident #21's room. CNA B stated Resident #12 had wandered into Resident #21's room and was standing at the end of Resident #21's bed with her arms folded. Continued interview revealed Resident #21 was swinging her arms, hitting Resident #12's arms. Continued interview revealed CNA B separated the residents and reported the incident to the charge nurse. During an interview on 5/9/2024 at 12:42 PM, the Assistant Director of Nursing confirmed the altercation between Resident #12 and Resident #21 occurred.

Based on the facility policy, medical record review, observation, and interview, the facility failed to follow physician orders for pressure ulcer treatments and failed to provide weekly pressure ulcer measurements for 3 residents (#2, #9, and #10) of 3 residents reviewed for pressure ulcers. The findings included: Review of the facility policy Skin Care Guideline, dated 7/2018, showed, .to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity .document evaluation of wound .including .location and staging .size (length x [times] width x depth) .exudate .pain .wound bed .reassess, re-evaluate and revise interventions when progress is not noted within 14 days .pressure ulcer identified .treatment as ordered . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, not dated, for Resident #2 showed a care plan for .actual impairment to skin integrity suspected of further skin break down .open areas' noted to right Trochanter [hip], Sacrum, (R) [right] Heel . Interventions included .monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Clinical Physician Orders for 7/1/2022 - 9/7/2022 showed 1) Clean area on right heel with wound cleanser, apply [MEDICATION(S)] AG (anti-microbial wound dressing) cover with dry dressing every day shift every Monday, Wednesday, Friday for wound care 2) Clean area on sacrum/right hip with wound cleanser, apply [MEDICATION(S)] AG cover with dry dressing as needed for wound care every Monday, Wednesday, Friday for wound care Review of the Treatment Administration Record (TAR), dated 7/2022, showed no wound care for 3 of 12 scheduled treatments on 7/6/2022, 7/15/2022, and 7/27/2022. Further review showed measurements, to be done weekly, documented 7/1/2022, 7/11/2022 (10 days later), and 7/22/2022 (10 day later). Review of the TAR, dated 8/2022, showed no wound care for 2 of 14 scheduled treatments 8/8/2022 and 8/12/2022. Further review showed measurements, to be done weekly, were documented 8/6/2022 (16 days later) and 8/15/2022 (9 days later). Review of Resident #2's Wound Evaluation, Stage 2, Right Heel, Age Unknown, acquired in-house, with measurements, were obtained 7/11/2022, 7/21/2022, and 9/7/2022. No measurements were documented for 8/2022. Review of Resident #2's Wound Evaluation Stage 3, Right Trochanter (hip), showed a pressure ulcer 9 months old, acquired in-house, with measurements obtained 7/11/2022, 7/21/2022, 8/6/2022, and 9/7/2022. Review of Resident #2's Wound Evaluation, Stage 3, Sacrum, showed a pressure ulcer 9 months old, acquired in-house, with measurements obtained 7/11/2022, 7/21/2022, and 9/7/2022. No documentation of sacrum wound measurements for 8/2022 was in the medical record or provided from the facility. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], showed dependance on staff for Activities of Daily Living (ADLs) including bed mobility, dressing, toileting, and hygiene. Section M, Skin Conditions, showed pressure ulcer/injury including 2 Stage 2 pressure ulcers and 2 Stage 3 pressure ulcers. During an interview on 9/8/2022 at 3:15 PM, the Assistant Director of Nursing (ADON) stated the facility failed to document wound care treatments for 3 dates in 7/2022 (7/1/2022, 7/15/2022, 7/27/2022) and 2 dates in 8/2022 (8/8/2022, 8/12/2022), and to follow their policy for weekly pressure ulcer measurements and confirmed partial weekly measurements were done 3 times in 7/2022, and 2 times in 8/2022. During a telephone interview on 9/8/2022 at 3:40 PM, and at 4:40 PM, the Medical Director stated it was his expectation the regime and treatment was carried out for Resident #2's pressure ulcers with weekly measurements .I expect it to be done .wasn't told about it .we need more consistency in documentation and measurements .he's not that compliant .the wounds have been about the same since he's been here .the numbers are all over the place .I don't think his wounds will ever heal up .he will not get better . He stated the heel and sacrum was the same and the trochanter/hip was better. During an interview on 9/9/2022 at 10:20 AM, the Director of Nursing (DON) confirmed the facility had no additional documentation on Resident #2's wound care treatment/dressing changes or measurements. She stated she was not aware of the length of days between wound measurements and stated she should have been aware of the missing dressing changes and measurements. She stated it was her expectation to do wound care as ordered and weekly measurements for pressure ulcers. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Care Plan, undated, showed a care plan .surgical area on her coccyx from debridement from a pressure ulcer and at risk for breakdown due to assistance required bed mobility, and a previous ulcer related to a [CONDITION(S)] with interventions for treatments as ordered . Review of Resident #9's quarterly MDS, dated [DATE], showed 1 Stage 4 pressure ulcer. Review of the Clinical Physician Orders dated 7/2022 - 9/9/2022, showed clean coccyx with wound cleaner apply Aqualcel AG, cover with comfort foam border or dry dressing every day shift every Monday, Wednesday, and Friday for wound care. Review of Resident #9's 7/2022 TAR showed coccyx pressure ulcer dressings were not documented on 5 days: 7/1/2022, 7/6/2022, 7/8/2022, 7/25/2022, and 7/29/2022. Review of Resident #9's 8/2022 TAR showed coccyx pressure ulcer dressings were not documented on 12 days: 8/1/2022, 8/3/2022, 8/5/2022, 8/10/2022, 8/12/2022, 8/15/2022, 8/19/2022, 8/22/2022, 8/24/2022, 8/26/2022, 8/29/2022, and 8/31/2022. Review of Resident #9's 9/2022 TAR showed coccyx pressure ulcer dressings were not documented for 2 days: 9/2/2022 and 9/7/2022. Review of Resident #9's Wound Evaluation, dated 7/2022, showed measurements done on 7/13/2022, 7/21/2022 (8 days later), and 7/27/2022. Review of Resident #9's Wound Evaluation, dated 8/2022, showed measurements were done once on 8/15/2022 (19 days later). Review of Resident #9's Wound Evaluation, dated 9/2022, showed measurements were done on 9/7/2022 (23 days later). During an interview on 9/9/2022 at 10:20 AM, with the DON and ADON, the DON stated she was not aware of any additional wound care documentation, was not aware of the length of days between measurements, and it was her expectation wound care was rendered as ordered with weekly pressure ulcer measurements. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Care Plan, undated, showed .actual impairment to skin integrity, open area noted to sacrum 8/31/2022 . Review of Resident #10's quarterly MDS, dated [DATE], showed 1 Stage 2 pressure ulcer. Review of Resident #10's Clinical Physician Orders, dated 9/9/2022, showed a to apply Augacel to sacrum area and cover with DermaRite (multilayered waterproof composite) dressing, 1 time a day every Monday, Wednesday, and Friday for wound care. Review of Resident #10's 9/2022 TAR showed the sacrum pressure ulcer dressings were not documented for 2 days: 9/2/2022 and 9/5/2022. During an interview on 9/9/2022 at 12:10 PM, with the DON and ADON, the DON stated the 2 wound care pressure ulcer treatments for Resident #10 were not documented. During a telephone call on 9/9/2022 at 1:45 PM, the Medical Director stated he was not aware wound care treatments and measurements were not done as ordered for Resident #2, Resident #9, and Resident #10.

Based on facility policy review, facility memo review, observation, and interview, the facility failed to separate resident and staff food items in 2 of 2 resident nourishment rooms, failed to date and label opened and/or prepared food items in 2 of 2 resident nourishment rooms, and failed to maintain a sanitary environment in 2 of 2 resident nourishment rooms possibly affecting 86 of 90 residents. The findings include: Review of the facility policy Facility Nourishment Refrigerators/and Nourishment Rooms, undated, showed .employees are to use the designated refrigerator in the employee break room. Any items that is not labeled, dated properly will be removed for safety . Review of the facility policy Use & [and] Storage of Food or Beverage from Outside Sources, dated 11/1/2016, .food or beverage that is brought in from the outside will be monitored .labeled with the resident's name, room number and dated . Review of the facility policy Resource: Food Safety for Your Loved One, dated 1/1/2017, showed .foods in unmarked or unlabeled containers should be marked with the current date the food item was stored . Review of a facility memo dated 4/14/2021 and taped to 2 of 2 resident nourishment refrigerators revealed .no personal items are allowed to be kept in the Nutrition Rooms .only Resident's belongings are to be stored in Refrigerator. It must have NAME AND DATE .ROOM NUMBER . During an observation and interview of the Harborside Kitchenette nourishment room on 6/29/2022 at 10:30 AM, with the Dietary Manager (DM) showed, inside the refrigerator labeled as the resident refridgerator, the following unlabeled, undated food items: 32 ounce (oz) opened hamburger dill pickles jar, a plastic bag with one 16-oz distilled water bottle, (identified) sliced banana cake in foil, 1 lunch tote with two 12-oz cans of lime soda water, small container of (identified) egg salad, 2 ham sandwiches, one 16-oz grated parmesan cheese, and one 8-oz green flavored smoothie drink. The freezer revealed 1unlabeled, undated, opened, melted, and refrozen 1-pint of peanut butter ice cream carton. During an interview the DM confirmed the facility failed to maintain resident and staff food items in a separate location and to date and label food items. Further observation revealed, under a dual working sink, an opened to air 40-pound bag of cat food, 1 paper towel roll with dried water spots, 1 coffee maker, 1 opened bottle of 16-oz dishwashing detergent, one 1-quart (qt) of liquid descaler, and two 1-qt cleaning vinegar solution. The inside of the cabinet showed black material on the walls and floor of the cabinet. During an interview the DM confirmed kitchen supplies and equipment were stored under a working sink. Continued observation and interview of the microwave showed dried food particles on the base, walls, and ceiling .it's filthy .looks like it's not been cleaned in a week . During an observation and interview on 6/29/2022 at 10:40 AM, of the Lighthouse Kitchenette nourishment room with the DM, showed in the refrigerator the following undated, unlabeled food items: one 16-oz opened hamburger dill pickle jar, one 32-oz refillable container with clear liquid, 3 small, dark colored cakes in a pizza box, one opened 1-liter of diet cola and 1-liter of opened orange soda, empty cheese wrappers, two 48-oz chocolate syrup bottles, two 22-oz caramel syrup bottles, and one 22-oz strawberry syrup bottle. The freezer revealed the following unlabeled, undated food items: 1 Korean style beef frozen entrée, and two 3-oz vanilla ice cream cups. During an interview the DM confirmed the facility failed to maintain resident and staff food items in a separate location and to date and label food items. Further observation and interview showed, under a dual working sink, 1 ice cream maker, one 32-oz peroxide multi-surface cleaner, two 32-oz all-purpose cleaner, one 32-oz empty cleaning bottle, 1 basin with 2 scrub sponges, 1 glass vase, 2 popcorn containers, 1 plastic lid, and 1 reusable drinking container with thick, flesh-colored liquid. On the floor of the cabinet showed a folded white blanket with dried colored stains. Under the blanket showed black debris on the cabinet floor and on the walls. During an interview the DM confirmed kitchen supplies and equipment were stored under a working sink. Continued observation and interview of the 1 of 1 microwave showed dried food particles on the base, walls, and ceiling. During an interview the DM confirmed the facility failed to maintain the cleanliness of the microwave. During an observation and interview on 6/29/2022 from 11:05 AM to 11:20 AM, with the DM and the Administrator, of the 2 nourishment rooms, the Administrator confirmed the facility failed to maintain separate areas for resident and staff food items .the policy is not being followed ., stated he was not aware kitchen equipment and other supplies could not be stored under a working sink, and the facility failed to maintain sanitary nourishment rooms for the residents.

Based on review of the facility's Resident Fund Statement, medical record review, and interview, the facility failed to ensure the trust fund accounts for 2 residents (#50 and #78) of 53 residents with trust fund accounts reviewed did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit. The findings include: Resident #50 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 1/1/2022-3/31/2022 revealed Resident #50 had a current balance of $10,761.88. Resident #78 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 1/1/2022-3/31/2022 revealed Resident #78 had a current balance of $4,634.43. During an interview on 6/29/2022 at 8:54 AM, the Business Office Manager stated it was her expectation to keep resident fund statements under $2,000.00. She further stated she became aware of the resident fund statements that exceeded $2,000.00 after she was hired on 4/19/2022. She confirmed Resident #50 had a balance of $10,761.88 and Resident #78 had a balance of $4,634.43 (over the $2,000.00 limit). During an interview on 6/29/2022 at 10:44 AM, the Regional Business Office Support (RBOS) stated Resident #50 had a balance that exceeded $2,000.00 on 6/2020, his money was not pulled from his trust from 6/2020-4/2021, she is unsure why the money was not pulled, there was no change in his liability. She further stated the money may be owed to a vendor, but they will need to call Medicaid to see what happened. Continued interview with RBOS stated Resident #78 had a balance that exceeded $2,000.00. The RBOS stated money had been pulled to pay an outstanding debt and to pay life insurance policy for Resident #78, by the daughter. The money was last pulled in 2021. The RBOS stated the facility had not contacted the daughter to see why the money was no longer being pulled from Resident #78's account.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a comprehensive care plan for Peripherally Inserted Central Catheter (a thin, long tube inserted into a vein in the arm for delivering medications and fluids) (PICC) care for 1 resident (Resident #5) of 19 residents reviewed for care plans. The findings include: Review of the facility policy titled, Care Plans and Baseline Care Plans, dated 6/2017 showed, .Care plans .developed for all .residents based .RAI manual guidelines .developed by the interdisciplinary team and revised as needed .resident .status or change . Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan initiated on 2/7/2022 and revised on 6/28/2022 showed, .Potential for Infection/complication r/t [related to] .Picc line .Change .dressings .caps according to the line type change schedule .order set . Review of a physician's order dated 3/14/2022 showed measure catheter length of IV PICC line on admission and with each dressing change weekly on Sunday. Review of a physician's order dated 3/14/2022 showed, change needleless connector on admission and weekly on Sunday, as needed, and change after every blood draw. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #5 was cognitively intact, had an IV (a tube in a vein that delivers medication and fluids), and was on isolation precautions. Review of physician's orders dated 6/14/2022 showed, change transparent dressing to IV (intravenous therapy) PICC line every Tuesday day shift. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview in Resident #5's room on 6/27/2022 at 11:45 AM with Licensed Practical Nurse (LPN) #1, LPN #1 stated the double lumen PICC in the left upper arm of Resident #5 had a dressing dated 6/14/2022 and did not have caps over the ports. LPN #1 confirmed the PICC dressing had not been changed in 13 days. During an interview on 6/29/2022 at 3:17 PM, the Director of Nursing (DON) confirmed staff had not implemented the care plan for PICC dressing and lumen cap changes. The DON stated she expected staff to implement Resident #5's care plan.

Based on the facility policy, medical record review, observation, and interview, the facility failed to follow physician's orders for 2 residents (Residents #5 and #67) of 19 residents reviewed for physician's orders. The findings include: Review of the facility policy titled, Physician and Nursing Services, dated 8/2020, showed, .This center follows guidance found in Appendix PP of the State Operations Manual regarding Physician and Nursing Services . Review of facility documentation titled, THE NURSES' INFUSION MANUAL FOR POST-ACUTE CARE FACILITIES, .Administration of an Intermittent Infusion . dated 8/1/2021, showed, .will have a new sterile [free from bacteria] end cap placed on the end of the administration set upon completion of each dose .Equipment .Sterile end cap .When infusion is completed .Place a new sterile end cap on end of administration set . Review of the facility documentation titled, PICC /Midline Care, instruction form undated, showed, .PICC dressing change every 7 days and PRN [as needed] . Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 3/14/2022 showed, measure catheter length of IV PICC line on admission and with each dressing change weekly on Sunday. Review of a physician's order dated 3/14/2022 showed, change needleless connector on admission and weekly on Sunday, as needed, and change after every blood draw. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #5 was cognitively intact, had an IV (a tube in a vein that delivers medicine or fluid), and was on contact isolation. Review of physician's orders dated 6/14/2022 showed, change transparent dressing to IV (intravenous therapy) PICC line every Tuesday day shift. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview in Resident #5's room on 6/27/2022 at 11:45 AM, Licensed Practical Nurse (LPN) #1, LPN #1 stated that the double lumen PICC in the left upper arm of Resident #5 had a dressing dated 6/14/2022 and did not have caps over the ports. LPN #1 confirmed the PICC dressing had not been changed in 13 days. During an interview on 6/28/2022 at 3:28 PM with Infection Control Nurse stated that the double lumen PICC line in the left upper arm of Resident #5 .should have been capped .the dressing should have been changed . and she expected the staff to follow the physician's orders for dressing changes. The Infection Control Nurse confirmed the staff had failed to change the dressing from 6/14/2022 to 6/27/2022 (13 days). During an observation in Resident #5's room on 6/29/2022 at 8:34 AM showed the PICC had been discontinued. During an interview on 6/29/2022 at 3:17 PM, the Director of Nursing (DON) confirmed the staff had not followed the physician's orders for dressing changes with measurements for the PICC on Resident #5. The DON stated it was her expectation for staff to follow physician's orders, for caps to be in place on the double lumen PICC, and measurements to be obtained as ordered by the physician. Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report showed an order dated 8/28/2020 for Complete Blood Count (CBC- a laboratory blood test) and Comprehensive Metabolic Panel (CMP- a laboratory blood test) every 6 months. Review of the medical record showed Resident #67 had a CMP drawn 8/5/2021 (10 months and 24 days ago). Review of the medical record showed Resident #67 had a CBC drawn 11/18/2021 (7 months and 11 days ago). During an interview on 6/29/2022 at 5:19 PM, LPN #2 stated she was responsible for ensuring labs were drawn according to the physician's orders. Resident #67 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 confirmed Resident #67 last had a CMP drawn on 8/5/2021 and a CBC was last drawn on 11/18/2021. Continued interview confirmed the physician's order for CBC and CMP every 6 months had not been followed. LPN #2 was unaware why the labs were not drawn. During an interview on 6/29/2022 at 5:28 PM, the DON confirmed it was her expectation that physician's orders were followed. The DON confirmed Resident #67's physician's order for CBC and CMP every 6 months were not followed. During a telephone interview on 6/29/2022 at 5:41 PM, the Medical Director stated Resident #67's order for CBC and CMP every 6 months was ordered for routine lab work. The Medical Director stated it was his expectation that physician's orders were followed and was unaware that Resident #67's every 6 month CBC and CMP labs were not drawn according to the order.

Based on facility policy review, facility fall investigation review, observation, and interview, the facility failed to ensure the correct mattress was placed on a bed frame resulting in a fall for 1 resident (#183) of 3 residents reviewed for falls. The findings include: Review of the facility policy Support Surfaces and Special Beds, undated, showed .complete patient assessment .patient's mobility .follow all safety measures to prevent injury to patients from accidental falls or improper positioning when placing them on special beds or mattresses . Review of the facility policy Falls, dated 2/2017, showed .identifies risk and establishes interventions to mitigate the occurrence of falls .when a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed . Review of the medical record showed Resident #183 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, [CONDITION(S)] (high levels of fat particles in the blood), and Dysphagia (difficulty swallowing) following Cerebral Infarction. Review of a facility fall investigation, dated 5/26/2022, revealed Resident #183 was found laying on 2 pillows on the floor, next to the bed .with the mattress hanging over the bed approximately 8 inches .he was too close to the edge of the bed and the mattress was hanging over the side, he slid into the floor taking his 2 pillows with him . Further review showed the immediate action taken by the facility .bed and mattress changed . Review of the Falls Care Plan, initiated 5/26/2022, revealed .bed and mattress changed .review information .attempt to determine cause of falls .the resident needs prompt response to all requests for assistance . Review of the 5-day Minimum Data Set (MDS) assessment, dated 5/31/2022, showed a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive function. Review of the Functional Status showed Resident #183 required extensive assistance with 2 staff for bed mobility and transfer. Ability to roll from left and right required partial/moderate assistance. Observation of Resident #183's semi-private room revealed a standard mattress and frame (assigned bed) and a bariatric (obesity) mattress and frame (unoccupied) in the room. Resident #183 was discharged and not present in the room. During a telephone interview on 6/27/2022 at 7:00 PM, Licensed Practical Nurse (LPN) #3 stated he was informed by a Certified Nursing Assistant (CNA) Resident #183 had fallen out of bed .the mattress was too far over .it had with the mattress partially off of the bed frame .we switched mattresses .he didn't have a roommate and we moved the mattresses over [from unused bed] . During an interview on 6/28/2022 at 10:40 AM, Central Service stated the facility had mattresses in 2 sizes: standard and bariatric. Both mattresses had the same length, but the bariatric mattress equaled an additional 7 inches in width to fit the bariatric bed frame. During a telephone interview on 6/28/2022 at 1:17 PM, CNA #2 stated he was assigned to Resident #183 the evening of the fall .he was on a bariatric mattress .we changed the mattress the next day . During an interview on 6/28/2022 at 2:00 PM, with the Director of Nursing (DON) and the MDS Coordinator #2, the DON confirmed the Fall Care Plan included bed and mattress change as an intervention. She confirmed it was her expectation an appropriately sized mattress should have been placed on the bed and was the responsibility of the nurses to oversee correct mattress placement. During an interview on 6/29/2022 at 11:30 AM, CNA #2 confirmed he noticed a bariatric mattress on Resident #183's bed and informed LPN #3 the evening of the fall. He stated LPN #3 instructed him to replace the mattress with the properly sized mattress after Resident #183 slid off the bed.

Based on review of facility Nurse Aide (NA-a noncertified employee performing direct resident care without completing the certification and competency evaluation) competencies and interviews, the facility failed to ensure employees working after June 7, 2022, the end of the COVID-19 Emergency Declaration Blanket 1135 Waivers, were actively seeking certification to become a Certified Nurse Aide (CNA) either through this challenge process or had enrolled in a traditional CNA Training program (NAT) for 4 NA employees (#1, #2, #3, #4) of 4 NA hired by the facility. The findings include: NA #1 was hired 12/7/2021 and had 470.18 logged hours worked as a NA. Review of the facility Temporary Nurse Aide Skills Competency Checklist showed NA #1 had completed it by 12/8/2021. Review of the Certification of Completion, Temporary Nurse Aide 8 Hour Training, dated 12/12/2021, showed NA #1 had completed her training. NA #2 was hired 4/12/2022 and had 44.7 logged hours worked as a NA. NA #2 had not completed the facility Temporary Nurse Aide Skills Competency Checklist or the Certification of Completion, Temporary Nurse Aide 8 Hour Training Course. NA #3 was hired 5/10/2022 and had 109.1 logged hours worked as a NA. NA #3 had not completed the facility Temporary Nurse Aide Skills Competency Checklist or the Certification of Completion, Temporary Nurse Aide 8 Hour Training Course. NA #4 was hired 6/14/2022 and had 44.7 logged hours worked as a NA. NA #4 had not completed the facility Temporary Nurse Aide Skills Competency Checklist or the Certification of Completion, Temporary Nurse Aide 8 Hour Training Course. During an interview on 6/29/2022 at 5:24 PM, the Infection Control/Clinical Educator and Minimum Data Set Coordinator #1 confirmed there were 4 staff members currently working in a NA capacity with the supervision of another CNA, none have challenged the process through application or have been registered in another NAT program through another facility.

Based on facility policy review, facility documentation review, medical record review, observation, and interview, the facility failed to ensure 3 of 38 staff followed infection control practices for 2 residents (Resident #5 and Resident #22) of 3 residents reviewed for transmission based precautions, and failed to ensure proper cleaning procedures were followed in 1 of 4 rooms reviewed for housekeeping services. The findings include: Review of the facility policy titled, Isolation Precautions for Infection Control, undated, showed .Contact .In addition to standard precautions .Gloves required upon entering room, Gown required if clothing may come into contact with the patient/resident or environmental surfaces or if the patient/resident has diarrhea . Review of the facility's policy titled, COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) Education, Prevention & [and] Response Guide, dated 3/2022, showed .How to Properly Put on and Take off a Disposable Respirator .Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator .The top strap (on single or double strap respirators) goes over and rests at the top back of your head. The bottom strap is positioned around the neck and below the ears .Checking Your Seal .Place both hands, over the respirator, take a quick breath in to check whether the respirator seals tightly to the face .Place both hands completely over the respirator and exhale. If you feel leakage, there is not a proper seal .If air leaks around the nose, readjust the nosepiece as described. If air leaks at the mask edges, re-adjust the straps along the sides of your head until a proper seal is achieved .If you cannot achieve a proper seal due to air leakage, ask for help or try a different size or model . Review of facility documentation titled, Personal Protective Equipment (PPE) Hazard Assessment Chart Housekeeping Services, undated, showed .Task .Contact isolation rooms .Vinyl gloves .Isolation Gown .Per IC [infection control] precautions face mask required .Cleaning Solutions .mop water .Changed after use in isolation rooms . Review of facility documentation titled, 5-Step Daily Room Cleaning form for In Service Program HOUSEKEEPING, for Housekeeper #2 and electronically signed on 5/3/2022, and for Housekeeper #1 electronically signed on 5/18/2022, showed .Mop all flooring surfaces .When damp mopping floors .Be sure to change the mop water every 3 rooms or sooner depending on the condition of the water . Review of facility documentation titled, Infection Control Overview & [and] Policy, for Housekeeper #2 and electronically signed on 5/3/2022 and for Housekeeper #1 electronically signed on 5/18/2022, showed .The purpose of this Infection Control Program .Investigate, control, and prevent infections in the facility .To comply with Centers for Medicare and Medicaid Services (CMS) guidelines .Preventing the spread of infection is the core of our environmental services department .Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions .Using proper chemicals and personal protective equipment when cleaning an isolation room .Infections and diseases are transmitted in several ways .Airborne .Contact .Droplet .Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room .Proper Use of PPE .it is important for staff to use appropriate personal protective equipment (PPE) as a barrier to exposure to any body fluids (whether known to be infected or not) . Review of facility documentation titled, RECORD OF IN-SERVICE, dated 6/16/2022, showed .Please see the attached information regarding the bacteria [CONDITION(S)] Pneumoniae [a bacteria which can cause a serious infection] .Please follow all infection control practices to reduce the risk of transmission. *PPE must be worn each time you enter the room* . Review of facility documentation titled, Course Completion History, showed Licensed Practical Nurse (LPN) #1 completed education on Infection Control: Essential Principles on 8/1/2021, on Infection Prevention and Control on 2/12/2022 and Principles of Infection Control on 2/19/2022. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders dated 2/3/2022 showed .Strict Contact Isolation Precaution . During an observation on 6/27/2022 at 12:45 PM, LPN #1 entered Resident #5's contact isolation transmission based precaution room. LPN #1 was observed wearing a cloth face mask underneath an N95 face mask and the N95 face mask had the bottom strap dangling underneath the chin. During an interview on 6/27/2022 at 12:50 PM, LPN #1 stated she had been un-vaccinated for COVID-19 and had not been given any instruction against the use of a cloth face mask with the use of a N-95 mask during resident care. LPN #1 confirmed she entered Resident #5 's transmission based precaution room without correctly donning the PPE. Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .for Highly Drug Resistant Organism . During an observation and interview on 6/27/2022 at 10:40 AM, 2 signs were posted on Resident #22's door. The first sign read .STOP .CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room .PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry. Discard gown before room exit .Do not wear the same gown and gloves for the care of more than one person .contact isolation signage on door .Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person . The second sign read .Contact Precautions .TO PREVENT THE SPREAD OF INFECTION .Perform hand hygiene before and after patient contact .Wear gloves upon entering this room .Wear a gown upon entering this room .Use dedicated or single use disposable patient equipment. When this is not possible disinfection of common use items is recommended .Contact Infection Prevention if you have questions . A 3-drawer plastic storage bin was outside Resident #22's room that contained gowns and gloves. Housekeeper #1 and Housekeeper #2 exited Resident #22's room and wore only a mask as PPE. Housekeeper #1 and Housekeeper #2 stated they were .unsure .had not been told . when asked if Resident #22 was in isolation. This surveyor pointed to the signs on Resident #22's door and both housekeepers stated .don't know .never been told .we were told if we were not providing direct patient care or touching the resident, we were not required to wear gowns or gloves, only masks . Housekeeper #1 and #2 stated residents in isolation had garbage cans in the room and an isolation bin outside the room. This surveyor pointed to the 3-drawer bin outside Resident #22's room and asked if this was what they were talking about, and both housekeepers confirmed yes. Housekeeper #1 and Housekeeper #2 then entered Resident #22's room again and did not don a gown or gloves. Housekeeper #2 carried the mop in the room, mopped the floor, brought the mop out of Resident #22's room, placed the mop in the mop water, and mopped 4 other resident rooms without changing the mop water. During an interview on 6/27/2022 at 11:31 AM, the Director of Housekeeping stated staff were in-serviced in infection control upon hire and periodically through staff meetings. The facility Infection Control Nurse assisted with training and in-services. The Director of Housekeeping stated housekeepers were aware of residents in isolation by signage posted on the door and isolation carts outside the room. Continued interview confirmed it was the Director of Housekeeping's expectation that housekeepers wore PPE listed on the signage posted on the door for isolation rooms and mop head and water be changed after use in an isolation room. During an interview on 6/27/2022 at 11:44 AM, Housekeeper #2 confirmed she did not change the mop head and mop water after mopping Resident #22's room, and continued to mop 4 other resident rooms without changing the mop water or mop head. During an observation and interview on 6/27/2022 at 1:27 PM, LPN#1 entered Resident #22's room and wore a N-95 mask with the bottom strap hanging underneath her chin and a cloth mask underneath the N-95 mask. LPN #1 did not don a gown and gloves for the resident care interaction with Resident #22. When asked if Resident #22 was in isolation, LPN #1 looked at the door and stated yes. LPN #1 confirmed she did not don appropriate PPE (gown and gloves) for the interaction with Resident #22. During an interview on 6/28/2022 at 2:30 PM, the Infection Control Nurse confirmed the County was in a high transmission category for COVID-19. She stated the facility used the Centers for Disease Control (CDC) guidelines for PPE usage to mitigate the spread of COVID-19 in the facility. The Infection Control Nurse stated the CDC guidance as of 2/22/2022, required use of a face mask and eye protection in resident care areas. The Infection Control Nurse confirmed LPN #1 was unvaccinated against COVID-19 and had not correctly donned the recommended or required PPE before entering a TBP room and the use of a cloth face mask underneath an N95 mask was not the correct use for the PPE. During an interview on 6/29/2022 at 5:00 PM, the Director of Nursing confirmed it was the expectation of the facility that staff follow isolation precautions and don the appropriate PPE for residents in isolation. Continued interview confirmed it was the expectation that mop heads and mop water were changed after use in isolation rooms.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 6 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy dated 1/2019 showed .Abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately .Mental Abuse is the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 7 indicating the resident had severe cognitive impairment. Review of the facility's investigation dated 2/27/2022 showed on 2/27/2022 at 10:00 PM Certified Nurse Assistant (CNA) #1 reported she went into Resident #1's room with Licensed Practical Nurse (LPN) #1 when the nurse attempted to give the resident her medications the resident became agitated and called the nurse an expletive. CNA #1 stated she witnessed LPN #1 throw Resident #1's blanket over her head and push the resident into bed with her hand over her face. Continued review of the investigation revealed LPN #1 denied putting her hand over Resident #1's face and pushing her into bed, however LPN #1 admitted to putting the blanket over Resident #1s head after the resident became upset and called her an expletive. Further review showed LPN #1 was terminated. During an interview on 3/15/2022 at 8:50 AM, the Director of Nursing (DON) stated .[LPN #1] admitted she threw the blanket over [Resident #1] but denied touching her so I couldn't substantiate that she touched her .we terminated [LPN #1] because I couldn't allow that type of behavior . During a telephone interview on 3/15/2022 at 10:30 AM, CNA #1 stated .I went in the room [Resident #1's room] with her [LPN #1] to show her which one the patient was because she didn't know the residents on that hall real well .[LPN#1] sat down on the side of [Resident #1] bed and she was trying to get [Resident #1] to take her meds [medications] and [Resident #1] was telling her she didn't take night time meds .she would not take them for [LPN #1] and [Resident #1] started calling [LPN #1] a [expletive] and told her to get out of her room and then [LPN #1] threw [Resident #1's] blanket over her head and took her hand and placed it over [Resident #1's] face over the blanket and she just eased her head back on the pillow and then she let go .after she done that [Resident #1] got the blanket off of her head and was screaming at [LPN #1] and told her not to come back in her room and we was already leaving the room as she was screaming . During a telephone interview on 3/15/2022 at 11:30 AM, LPN #1 stated .I asked the [CNA #1] to accompany me in [Resident #1's] room .I pulled the cover off of [Resident #1's] head because she had her head covered up and I told her I had her medicine and she said I don't take pills at night .she said I told you I don't take any [expletive] meds at night .she said you can get the F out of here and leave me like you found me so I put the cover back over her head and then walked out of the room .that was it I didn't touch her .I was on administrative leave for 8 days and then they terminated me .

Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to protect 1 resident (Resident #1) from verbal abuse of 5 residents reviewed for abuse. The findings include: Review of the facility policy titled, Review of Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, stated .Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's comprehensive Care Plan dated revised 8/5/2021 and 11/8/2021 for Resident #1 revealed .verbally aggressive behavior .Physically aggressive behavior . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 had a Brief Interview for Mental Status score of 11 indicating she was moderate cognitive impairment. The MDS showed Resident #1 required physical assistance of 1 person for bed mobility, toilet use, and personal hygiene. Review of a Significant Change MDS assessment dated [DATE] showed Resident #1 had a Brief Interview for Mental Status score of 5 indicating she was severely cognitively impaired. The MDS showed Resident #1 required physical assistance of 1 person for bed mobility, toilet use, and personal hygiene. Review of facility documentation dated 11/2/2021 revealed Certified Nursing Assistant (CNA) #1 stated .She [Nurse Aide in Training (NAIT)] came in and as holding [Resident #1's] hand trying to calm her down. Then [Resident #1] pulled their hands towards her mouth and tried to bite [NAIT]. [NAIT] pulled her hands away and said not to bite her .she said if she bites her she's gonna punch her in the face. That she [NAIT] doesn't like biters . Review of facility documentation dated 11/2/2021, revealed CNA #2 stated .[CNA #1] and I were changing [Resident #1] .she became combative with us .asked her [NAIT] to help us .[Resident #1] began trying to bite [NAIT] .[NAIT] told [Resident #1] 'Do not bite me. If you bite me. I will punch you in your face. I don't like biters' . Review of facility documentation dated 11/2/2021 revealed Registered Nurse (RN) #1 stated .As the RN Supervisor on duty at 20:06 [8:06 PM] it was brought to my attention that a staff member verbally threatened a resident . During an interview on 11/22/2021 at 12:00 PM Resident #1 was unable to answer questions due to cognitive impairment. During an interview on 11/22/2021 at 1:47 PM the Director of Nursing (DON) stated RN #1 called to report a verbal abuse allegation. CNA #1 and CNA #2 reported to RN #1 that the NAIT told Resident #1 on 11/2/2021 if she bit her, she would punch her in the face because she did not like biters. During an interview on 11/22/2021 at 2:15 PM CNA #1 stated on 11/2/2021 she and CNA #2 went into Resident #1's room. CNA #1 stated the resident was combative and they requested assistance from the NAIT. CNA #1 stated the NAIT held Resident #1's hand for comfort. The resident pulled her hand up and attempted to bite the NAIT. CNA #1 stated the NAIT told Resident #1 If you bite me I'm going to punch you in the face, I don't like biters. During a telephone interview on 11/22/2021 at 4:50 PM RN #1 stated on 11/2/2021 Licensed Practical Nurse (LPN) #1 reported CNA #1 and CNA #2 reported the NAIT was holding Resident #1's hands for comfort when the resident pulled her arm and attempted to bite her. The CNAs told LPN #1 the NAIT threatened to punch Resident #1 in the face if she bit her. During a telephone interview on 11/23/2021 at 11:45 AM, the Administrator stated the Nurse Aide in Training verbally abused Resident #1 on 11/2/2021.

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to report an allegation of abuse for 1 resident (Resident #2) of 5 residents reviewed for abuse. The findings include: Review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy dated 1/2019, showed .To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations .Alleged Violation: A situation or occurrence that is observed or reported by team member, resident, relative, visitor or others but has not yet been investigated .Alleged violations/violations will be reported to the Administrator, designee immediately . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had a Brief Interview for Mental Status (BIMS) of 2, indicating severe cognitive impairment, and the resident locomoted throughout the unit with a wheelchair. Review of the comprehensive care plan resolved on 10/11/2020, showed Resident #2 was care planned for Alzheimer's, Dementia, and Behaviors. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan resolved on 2/8/2021, showed Resident #1 was care planned for Dementia. The care plan was reviewed for any needed revisions on 7/14/2020, and no updates were noted on the care plan. Review of the quarterly MDS assessment dated [DATE], showed Resident #1 had a no BIMS score documented, an indication of moderate cognitive impairment for daily decision making was documented, and the resident independently ambulated throughout the unit. Medical record review of a progress note for Resident #1 dated 7/14/2020 at 8:22 PM, showed a Licensed Practical Nurse (LPN) #1 had documented physical contact by Resident #1 towards Resident #2, .[Resident #1] .struck [Resident #2] with her hand in the side of her face, no injury, took [Resident #1] to her room . During an interview on 9/8/2021 at 2:00 PM, with the Interim Administrator and the Director of Nursing Services (DNS) #1 in the Interim Administrator's office, the Interim Administrator confirmed he could not produce any documentation regarding the resident-to-resident contact. The DNS stated she had not been made aware of the incident and this was the first that she had heard anything about it. Further interview with the Interim Administrator and DNS #1 confirmed the resident-to-resident altercation was not reported to the State Agency. During a telephone interview on 9/8/2021 at 2:26 PM, the former Assistant Director of Nursing Services (ADNS) #1 stated she was notified of the resident-to-resident contact from LPN #1 and stated she had reported the incident to the DNS #1. Continued interview revealed the ADNS #1 stated she had followed up with DNS #1 and it was conveyed to her .Everything was taken care of . During a telephone interview on 9/8/2021 at 3:30 PM, LPN #1 stated she had received training on abuse and reporting abuse. LPN #1 confirmed she had reported the incident to her supervisor (no name); LPN #1 then stated she thought her supervisor was to have completed the reporting process instead of her. LPN #1 confirmed it was a misunderstanding on her part of not reporting the incident, and confirmed she did not follow up further with her supervisor regarding the resident-to-resident contact. During an interview on 9/9/2021 at 2:25 PM, the Interim Administrator confirmed he had no knowledge of the incident of Resident #1 contacting Resident #2 until it was reported to him by the surveyor on 9/8/2021. The Interim Administrator confirmed there should have been an incident report completed and the incident should have been reported to the State Agency.

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to investigate an allegation of abuse for 1 resident (Resident #2) of 5 residents reviewed for abuse. The findings include: Review of the facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy dated 1/2019, showed, .Alleged violations/violations will be reported to the Administrator, designee immediately .Investigation .The Administrator will oversee .an internal investigation against any violation/alleged violation of abuse . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had a Brief Interview for Mental Status (BIMS) of 2, indicating severe cognitive impairment, and the resident locomoted throughout the unit with a wheelchair. Review of the comprehensive care plan resolved on 10/11/2020, showed Resident #2 was care planned for Alzheimer's, Dementia, and Behaviors. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan resolved on 2/8/2021, showed Resident #1 was care planned for Dementia. The care plan was reviewed for any needed revisions on 7/14/2020, and no updates were noted on the care plan. Review of the quarterly MDS assessment dated [DATE], showed Resident #1 had no BIMS score documented, an indication of moderate cognitive impairment for daily decision making was documented, and the resident independently ambulated throughout the unit. Medical record review of Resident #1's progress note for dated 7/14/2020 at 8:22 PM, showed a Licensed Practical Nurse (LPN) #1 had documented physical contact by Resident #1 towards Resident #2, .[Resident #1] .struck [Resident #2] with her hand in the side of her face, no injury, took [Resident #1] to her room . During an interview on 9/8/2021 at 12:50 PM, with the Interim Administrator, a request for facility documentation/investigation of the resident-to-resident altercation that occurred on 7/14/2020. During an interview on 9/8/2021 at 2:00 PM, with the Interim Administrator and the Director of Nursing Services (DNS) #1 in the Interim Administrator's office, the Interim Administrator confirmed he could not produce any documentation regarding the resident-to-resident altercation. The DNS stated .I had not been made aware of the incident and this was the first that I had heard anything about it . Further interview with Interim Administrator and DNS #1 confirmed the resident-to-resident altercation was not investigated. During a telephone interview on 9/8/2021 at 2:26 PM, the former Assistant Director of Nursing Services (ADNS) #1 stated she was notified of the resident-to-resident contact from LPN #1 and stated she (ADNS #1) had reported the incident to the DNS #1. Continued interview confirmed ADNS #1 had followed up with DNS #1 and it was conveyed to her .Everything was taken care of . The ADNS #1 did not verbalize an investigation was initiated after learning of the altercation. During an interview on 9/9/2021 at 2:25 PM, the Interim Administrator confirmed he had no knowledge of the incident of Resident #1 contacting Resident #2 until it was reported to him by the surveyor on 9/8/2021. The Interim Administrator confirmed there should have been an incident investigation completed.

Based on review of facility policy, medical record review, review of facility investigations, review of personnel files, review of employee attendance records (time punch), and interview, the facility failed to prevent mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed. The facility's failure to prevent abuse resulted in psychological abuse to Resident #4 and placed Residents #4, #2, #3, #1, #17 and #18 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F 600 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, . 'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and Certified Nursing Assistant (CNA) #7 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility, but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review revealed LPN #4 reported on 2/20/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Interview with Resident #4 on 3/13/18 at 11:20 AM, in the resident's room, confirmed, .The only challenge I had .1 of the nurses was less than nice to me .(LPN #1) .she was always so mean .I asked others have I done something to her .once I had a rash and she reached across grabbed my arm and almost jerked me out of bed to look at it . Continued interview confirmed, while she was at physical therapy, .someone had ransacked my purse .garment bag .happened 2-3 times .the CNAs told me who it was .and it was (LPN #1) .it got to where I was refusing to go to physical therapy .refusing to go out to eat .I felt so violated .now that I am working out (working with physical therapy) my headaches are getting better .less intense .activities helping .and coffee .(LPN #1) would say 'you didn't eat your meal so no coffee' .went a week or two without coffee .if she was here I wouldn't come out of my room .didn't say anything initially because I didn't want to have repercussions .I honestly felt hatred from her .I asked to make a call .she just yelled and pointed 'go back to your room' . Continued interview confirmed Resident #4 told LPN #1 about her room being .ransacked . and LPN #1 responded .well is anything missing . and when Resident #4 said No LPN #1 responded .well what's the problem then . Further interview confirmed since LPN #1 had been gone, Resident #4 had been getting out of her room for meals and physical therapy. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Further interview confirmed LPN #1 had been dealing with stress and the facility offered her counseling and .provided her with everything we (the facility) could for stress . Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Further interview confirmed Resident #4 had been more active in therapy and the DON had noticed a difference in Resident #4's mood since LPN #1 had been terminated. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review revealed CNA #4 reported .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(continued) for 2 weeks .(LPN #1) has a stern voice . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .I gave it anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when the residents ask. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluting her medication from drinking too much water). Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that .I proceeded giving it (water) to (Resident #3) .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18, following a planned medical leave initiated on 2/17/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed Preventing, Recognizing, and Reporting Abuse education on 1/12/18 and Resident Rights education on 12/6/17. Continued review revealed no documentation a background check had been completed. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Continued interview confirmed .come to believe at different occasions (LPN #1) has lied to me .had to move her .it was related to interactions with other staff members . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room (on 2/14/18) .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her (CNA #1) every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the ADON on 3/13/18 at 2:59 PM, in the conference room, confirmed .I was told by (LPN #5) that (CNA Trainee #1) reported (CNA #1) smacked a resident .not sure if that was the correct terminology .was not 100% sure . Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18, she felt the staff were not able to identify specific examples of abuse, such as restricting fluids, because it is .kind of a fine line . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, revealed .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed .I didn't understand it (the allegations reported by CNA Trainee #1) to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview revealed the Administrator stated, staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .we don't have cameras .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse .

Based on review of facility policy, review of facility investigations, medical record review, review of personnel files, and interview, the facility failed to report in a timely manner mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed for abuse. The facility's systematic failure to report allegations of abuse immediately to administration, and within 2 hours to the state authorities, including the State Survey Agency, as required by Federal regulations, placed Residents #4, #2, #3, #1, #17 and #18 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F 609 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of resident/patient's property .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .(alleged violations), are reported immediately to the Administrator/Director of Nursing of the center . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time .(Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things .(LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the state authorities, including the State Survey Agency. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18 where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported . (LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .(LPN #1) would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .(continued) for 2 weeks . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #3 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .(ADON) came to me .I told her everything . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she did not report CNA #1's abuse immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or two .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information .wanted to go to the highest person I could .there's been a lot of talk .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .(ADON) tried calling me on the 15th at night .I was picking up my grandson .was out of cell service at that point in time .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't write down when I was called .I didn't tell (ADON) to report it (the State Survey Agency) .I didn't understand it to be abuse at that time .I took it as a complaint .we reported it (the State Survey Agency) .on the 16th .got a hotline call too .on the 16th .started investigation Interview with DON on 3/20/18 at 12:50 PM, in the conference room, confirmed she did not know why staff did not immediately report LPN #1's abuse to administration. Continued interview confirmed the facility did not report the allegation of abuse for Resident #2 and #3 by LPN #1 to the to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Further interview confirmed the facility did not report the allegation of abuse to the State Authorities including the State Survey Agency for Resident #4 by LPN #1 after they became aware on 2/19/18. Continued interview confirmed the facility failed to follow their abuse policy. Refer to F-600

Based on facility policy review, review of facility investigations, and interview, the Administer failed to ensure residents were free from mental, physical, and verbal abuse; to ensure allegations of abuse were reported immediately to facility administration and within two hours to State Authorities, including the State Survey Agency; and to ensure facility training was implemented to prevent abuse. The Administrator's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Immediate Jeopardy is effective 2/14/18 and was removed 3/21/18. The facility provided an acceptable Allegation of Compliance (AoC), with a compliance date of 3/21/18, and a revisit survey conducted 4/9/18 - 4/10/18 validated the corrective actions implemented by the facility removed the Immediacy of the Jeopardy. Noncompliance continues for F-835 at an E level for the facility's monitoring of the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes implemented by the facility. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Residents #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to State Authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the State Authority. Interviews with CNA #3, CNA #4, CNA #5, CNA #6 on 3/12/18 and 3/13/18 revealed they all witnessed actions by LPN #1 that met the facility's definitions of abuse but did not stop the LPN from abusing residents and did not report the LPN's actions to administration. Interviews with CNA #4 and CNA #6 revealed they did not report abuse to administrative staff because they thought facility administration did not act on allegations of abuse. Interview with Registered Nurse (RN) #1 (RN responsible for the CNA Training Program) on 3/14/18, at 9:02 AM, in the conference room confirmed, RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed she and CNA Trainee #1 witnessed CNA #1 slap Resident #1. CNA #6 stated .I didn't say anything .I know I should have . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she witnessed CNA #1 slap Resident #17's hand and Resident #1's hand on separate occasions. Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating . when you report to the person you're supposed to .it gets swept under the rug . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Further interview confirmed he did not know why staff on the locked unit did not report abusive behaviors .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Interview with the DON on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of abuse and reporting, but no change was implemented to correct the issue. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18, but no change had been implemented. Refer to F-600 (K); F-609 (K); F-841 (K); F-867 (K); F-943 (K). Validation of the AoC was completed 4/9/18 - 4/10/18 through review of facility documentation, observations, and interviews. Surveyors verified the AoC by: 1. Review of the facility's documentation revealed leadership staff conducted interviews with 100% of all alert and oriented residents with on 3/15/18 as part of their investigation for allegations of abuse. Continued review revealed there were no concerns on 3/15/18 regarding any further allegation of abuse. 2. Review of the facility education log book ensuring that 100% of all staff, including contract employees, was educated by the Activity Director, Director of Clinical Education, and Human Resource Director utilizing the Team Member Interview Tool was completed on 3/21/18. Education occurred between 3/15/18 - 3/21/18. Further review revealed 100% of staff were educated on the facility abuse policy and completed an interactive posttest with a score of 100% on 3/21/18, with the exception of 1 staff member who was unavailable. The staff member was educated on 3/21/18 via telephone by Director of Nursing and was not permitted to work until completion of the interactive posttest which was completed on 3/23/18. Review of the Team Member Interview Tool, posttest, and interviews with the facility leadership staff on 4/9/18 and 4/10/18 confirmed 100% of the active staff had been educated on abuse and facility policies by 3/21/18. 3. Review of the facility's Skin and Body Audit documentation revealed all residents underwent a body audit on 3/15/18, completed by the MDS Coordinators, Wound Care Nurse, ADON, and Unit Manager and no concerns related to abuse were identified. 4. Review of facility documentation revealed every resident representative was contacted either in person or by phone to determine if the resident they represented had ever been abused or ever witnessed abuse at the facility. Further review revealed the Activity Director completed the interviews of 60 out of the 82 resident representatives on 3/15/18, 22 representatives did not return the facility's 2 contact attempts. 5. Review of facility documentation revealed every resident representative was mailed information including a summary of Resident Rights, name and telephone number of the local Ombudsman, education regarding abuse and how to report abuse, and facility's Care Line number and website. 6. Review of facility in-service documentation revealed the Governing Body was provided education by the Regional Vice President (RVP) regarding clarification of the facility abuse policy and Abuse Coordinator on 3/15/18 at 9:00 AM. Interviews conducted on 4/9/18 and 4/10/18 with the Governing Body confirmed knowledge of the facility abuse policy, state, and federal regulations for reporting abuse, and the role of the abuse coordinator. 7. Review of facility in-service documentation revealed the Medical Director was provided education by the administrator on 3/28/18 regarding his roles and responsibilities. Telephone interview with the Medical Director on 4/10/18, at 10:50 AM confirmed knowledge of the facility abuse policy and his responsibilities. Further interview confirmed has been in attendance for QAPI meetings on 3/14/18 and 3/21/18, and has given the facility recommendations for educating staff on the importance of abuse and abuse reporting, as verified in meeting minutes. 8. Review of facility orientation packet revealed the addition of a new 50 question Abuse Test and Abuse Education Posttest. Interviews with the facility leadership on 4/9/18 and 4/10/18 confirmed the education will be verified by the DON or a Registered Nurse before staff can provide direct patient care. 9. Review of the Resident Council Meeting Minutes dated 3/16/18 and interview with the Resident Council President on 4/9/18, at 3:05 PM, in the dining hall confirmed all 20 residents in attendance were educated on Resident Rights and abuse. Interviews conducted on 4/9/18 and 4/10/18 with 4 cognitively intact residents who did not attend the resident council meeting on 3/16/18 confirmed they were recently informed of their rights and abuse by facility staff. 10. Review the facility log book of continuing audits which began on 3/15/18 included interviews with 10 staff members per week regarding abuse and abuse reporting and will continue every week for 8 weeks. Interview with the RVP on 4/10/18 at 12:50 PM confirmed the weekly audits will continue after the 8 weeks, as long as they are needed, but no less than quarterly. Observation on 4/9/18 at 10:30 PM revealed the Clinical Educator and ADON were conducting staff interviews as part of the facility audit process in relation to abuse and abuse reporting. 11. Review of the facility Quality Assurance Performance Improvement (QAPI) meeting minutes dated 3/14/18, 3/21/18, 3/27/18, and 3/29/18, revealed the facility continued to review audits regarding staff knowledge of abuse and abuse reporting. 12. Observation on 4/9/18 and 4/10/18 revealed the RVP and Director of Clinical Operations were present at the facility. 13. Verification through interviews with 5 contracted Housekeeping and Physical Therapy employees was conducted during the revisit survey on 4/9/18 to confirm the staff's understanding of facility policies for abuse and abuse reporting. 14. Verification through interviews with 1st shift licensed nurses and Certified Nurse Assistants (CNAs) was conducted during the revisit survey on 4/9/18 between 10:00 AM and 2:45 PM to confirm the staff's understanding of abuse and abuse prohibition. 15. Verification through interviews with 2st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 2:00 PM and 4:00 PM to confirm the staff's understanding of abuse and abuse prohibition. 16. Verification through interviews with 3st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 10:00 PM and 11:30 PM to confirm the staff's understanding of abuse and abuse prohibition. 17. Verification through interviews with Leadership Staff, including the Medical Director and RVP, on 4/9/18 and 4/10/18 were conducted to confirm understanding of the facility's abuse policy, their role and responsibility in ensuring resident safety, abuse reporting, and the facility's system for monitoring compliance. 18. Interviews were conducted with 8 residents during the revisit survey on 4/9/18 and 4/10/18 revealed no residents had concerns about being abused or seeing any other resident being abused. 19. Attempts made to contact 3 resident representatives with 1 successful interview on 4/10/18 at 2:31 PM revealed no concerns regarding abuse or witnessed abuse. Further interview confirmed the representative was recently educated by facility staff on abuse and how to report abuse. 20. During the revisit survey conducted on 4/9/18 and 4/10/18, the facility was made aware of an allegation of neglect by a family member of a former resident. The facility followed state and federal regulations in reporting the allegation of neglect in a timely manner.

Based on facility policy review, review of facility investigations, Quality Assurance and Performance Improvement (QAPI) committee documentation, and interview, the Medical Director failed to participate in the implementation of resident care policies to ensure all residents were protected from abuse. The Medical Director's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff wtinessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 2/21/18 revealed the Medical Director attended the QAPI meeting. Telephone interview with the Medical Director on 3/21/18 at 9:12 AM, confirmed he had been made aware of residents not being provided water and he reviewed labs for those residents. Continued interview revealed the Medical Director was a member of the QAPI program and stated he had knowledge of .a couple of staff fired due to abuse . The Medical Director stated he had no further input, other than the medical assessment, into any other facility changes or updates to facility policy as a result of alleged abuse. The Medical Director stated, .I leave that up to them . Refer to F-600 (K); F-609 (K); F-867 (K); F-943 (K).

Based on facility policy review, review of facility investigations, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and report abuse, as well as, implement corrective action plans to prevent abuse. The QAPI's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to state authorities, including the State Survey Agency. Interview with the Director of Nursing (DON) on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of what constituted abuse and staff reporting of abuse. Interview with the DON on 3/20/18 at 12:48 PM, in the conference room, and review of the QAPI meeting attendees and meeting minutes, confirmed the DON was part of the QAPI team and a meeting was held on 2/21/18. During the QAPI meeting the identified concern with staff understanding and reporting of abuse was not brought to QAPI for discussion and implementation of a corrective action plan. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18. Review of the QAPI meeting minutes with the Administrator on 3/21/18 at 8:48 AM, by phone, confirmed the Administrator was part of the QAPI team and attended the meeting held on 2/21/18. The Administrator confirmed the concern of staff understanding and reporting of abuse was not discussed in QAPI for implementation of a corrective action plan. Refer to F-600 (K); F-609 (K); F-835 (K); F-841 (K); F-943 (K).

Based on review of facility investigation, review of facility abuse training documentation, review of personnel files, and interview, the facility failed to implement an effective training program for staff on the prohibition and reporting of all forms of abuse and neglect. The facility's systematic failure placed 6 Residents (#4, #1, #2, #3, #17, and #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (Licensed Practical Nurse (LPN) #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to (Resident #2) sternly and talks to her rudely. (LPN #1) will not allow (Resident #2) to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed LPN #4 initially denied witnessing anything she considered abuse on 2/16/18 but reported on 2/19/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Continued review revealed on 2/19/18, LPN #4 reported .(LPN #1) talks mean to (Resident #2) . will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Continued review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18 CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when they asked. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluted medication effects from drinking too much water). Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed in an interview conducted on 2/21/18, between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review of the facility abuse investigation initiated on 2/16/18 revealed on 2/14/18, CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room, took a food tray from Resident #18 before her meal was finished, and smacked Resident #1's hand twice during a shower. Continued review revealed CNA Trainee #1 reported CNA #1 saying to Resident #1 in the shower after Resident #1 smacked CNA #1 .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the shower allegation but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Review of the facility's required education orientation revealed it consisted of review of the facility's abuse policy and Hand in Hand training. Continued review revealed an annual computer based training course Preventing, Recognizing, and Reporting Abuse which included definitions of abuse, how to report abuse, scenarios regarding abuse, and a post test. Review of LPN #1's Personnel File revealed LPN #1 was hired on 10/23/09, started a planned medical leave on 2/17/18, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 1/12/18. Review of CNA #1's Personnel File revealed CNA #1 was hired on 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA Trainee #1's Personnel File revealed CNA Trainee #1 was hired on 1/22/18 and had not started the Preventing, Recognizing, and Reporting Abuse computer based education prior to working on the unit but completed the required abuse training provided in orientation. Interview with CNA #3 on 3/12/18, at 11:04 AM, in the Lighthouse Dining Room confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she didn't want to get up .make her get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(went on) for 2 weeks .(LPN #1) has a stern voice . Review of CNA #3's education documentation revealed CNA #3 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/4/18. Interview with CNA #4 on 3/12/18, at 11:14 AM in the Lighthouse Dining Room confirmed abuse .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water .because she would play in it .I gave anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Review of CNA #4's education documentation revealed CNA #4 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #5 on 3/13/18, at 10:13 AM, at Lighthouse nurses' station confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication from drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that (water) .I proceeded giving it to her .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report (allegations of abuse) to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of CNA #5's education documentation revealed CNA #5 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #6 on 3/13/18, at 10:27 AM, at the Lighthouse nurss' station confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNA's say they told them before and it doesn't get fixed . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with the Activities Director on 3/14/18, 8:45 AM in the conference room confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you she thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) .did not report it to (the administrator) .reported it to her supervisor . Interview with RN #1 on 3/14/18, at 9:02 AM, in the conference room confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy .do (computer based) training .usually go around .in-services .reviewing with them different types of abuse and how to report it .when just reviewing .go over the policy .in classes more in depth . Continued interview confirmed RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed .it was me and a student at the time .I could hear slap .I don't think she said anything .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Telephone interview with CNA Trainee #1 on 3/14/18, at 9:47 PM, confirmed .I was helping in the shower room that day (2/14/18) .after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at her hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .couldn't tell you what (Resident #17's) face looked like .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Continued interview confirmed .I was helping in shower room again .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Continued interview confirmed the next time she witnessed abuse was .lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact . Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or 2 .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't know it was an allegation of abuse .(CNA Trainee #1) came forth and gave some information .I didn't understand it to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Further interview confirmed the staff was educated on abuse by computer based training which had tests. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her and made her fearful to leave her room. Further interview confirmed the DON conducted daily rounds where she talked with staff and residents and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Interview with the Administrator on 3/14/18, at 5:23 PM, in the conference room confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview confirmed staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Refer to F-600 and F-609