Every finding on record at Cambridge Nursing & Rehabilitation Center

Based on observation, interview, and review of the facility's policies, the facility failed to ensure resident food was stored and prepared in a safe and sanitary manner. The deficient practice potentially affected 106 current residents who received food from the kitchen. The findings include:Review of the facility's policy titled, Food Storage, last reviewed 08/20/2025, revealed foods would be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Further review revealed all foods should be covered, dated, and labeled to assure foods would be safely consumed by their use by or expiration dates. Continued review revealed, for dry storage, food should be dated if removed from the shipping container/box (which contained the delivery date on the label). Review of the facility's policy titled, Employee Sanitary Practices, undated, revealed all food and nutrition services employees would practice good personal hygiene and safe food handling. Further review revealed all employees would wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. 1.Observation on 02/15/2026 at 11:25 AM revealed two 128-ounce jars of mayonnaise and one 128-ounce jar of sweet pickle relish, which were unopened but out of the original box packaging, undated. Further observation revealed a 36-ounce box of au gratin potatoes with no opened date. Continued observation revealed an opened bag of cereal that was rolled up and placed on a shelf, unsealed and undated. Additional review revealed an opened box of 1000 coffee creamers, 2.5-gram packets, with no received date. Observation of the walk-in freezer revealed an opened 30-pound bag of frozen sweet peas, inside an opened box, with no opened date. Further review revealed an opened case of 210 frozen, 1.2-ounce biscuits with no opened date. During an interview with the Head [NAME] on 02/15/2026 at 11:25 AM, he stated the received date was important so staff could calculate the use by date, and all items should have been dated. 2.Observation on 02/15/2026 at 12:05 PM revealed Dietary Aide (DA) 1 at a food preparation table before the lunch meal with a hair bonnet that only partially restrained her hair, and her bangs and her hair on both sides of her face were loose from restraint.During an interview with the Dietary Manager (DM), on 02/15/2025 at 11:35 AM, he stated DA1 should have a hairnet under the bonnet that restrained all her hair, to prevent it from falling into and contaminating food. He further stated hairnets were required for anyone coming into the kitchen.During an interview with DA2 on 02/18/2026 at 3:19 PM, she stated when the food truck was unloaded, staff first went to the freezer, then to the refrigerator, and then to dry storage. She stated staff marked, with a sharpie, the received date on the box or container. Then when opening containers or boxes, she stated, staff marked the items inside the box or container with the date opened. She stated that it was important so staff did not give a resident old or expired food or so staff knew if there was too much of something that needed to be stored elsewhere. She stated that it was important because old or expired food could make the residents sick from bacteria. She stated all staff must wear hair restraints at all times including over beards. She stated if a staff member wore a bonnet, they still had to wear a hair net, so no hair got in the residents' food. She stated anyone who came into the kitchen must wear a hair net. She stated that it was important for infection control because hair was exposed to the home, outside, or wherever anyone had been.During an interview with DA3 on 02/18/2026 at 4:24 PM, he stated staff labeled food with the day's date when items were delivered, and new items went to the back, so items were used first in, first out. He also stated after opening a box or container, the items must be labeled with the opened date. He stated that it was important, so staff knew how long it had been opened. He stated if the food was kept too long, it could go bad and make the residents sick. DA3 stated everybody was supposed to have a cover on their hair, and all hair had to be restrained. He stated that it applied to anyone who came into the kitchen for any reason. He stated hair restraint was necessary, so hair did not get in food because it was unsanitary. During an additional interview with the Head [NAME] on 02/18/2026 at 3:48 PM, he stated staff dated delivered items to prevent them from using food that was not safe, as they did not want to give residents expired food that could make them sick. He stated opened bags should be wrapped in plastic wrap and dated. He stated the expectation for hairnets was everyone who came into the kitchen wore them at all times with all hair contained, and it was important to prevent cross contamination, as hair could be dirty or have lice. He stated a bonnet was not appropriate because it could be worn outside and potentially exposed to something infectious.During an additional interview with the DM on 02/18/2026 at 4:40 PM, he stated when storing delivered food, staff must date and label the food with the received date. He also stated when a box was opened and the item removed; staff also must label the item with that date. He stated dating was important, so the staff knew what went out to be used, and the point was to have fresher foods. He stated that process was a safety precaution for preventing foodborne infection by using old, expired food. He stated the purpose of everyone wearing hair nets was to keep hair off plates, trays, and food, and it was an infection control measure as hair could contaminate food. He stated anyone in the kitchen must have all hair restrained.During an interview with the Administrator on 02/19/2026 at 5:42 PM, he stated his expectation was that the kitchen staff followed policy to date stored food items and remaining food items after opening the container to be dated and stored per the facility's policies. He further stated his expectation for kitchen staff was that they wear a hair restraint with all hair covered, as required for anyone in the kitchen.

Based on observation, interview, record review, review of the manufacturer's recommendations for the facility's glucometers, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 12 out of 24 sampled residents, Resident (R) 3, R19, R26, R35, R41, R42, R44, R48, R55, R60, R94, and R102 and for 1 of 2 working shower rooms, the East Wing Shower Room. The findings include:Review of the Centers for Disease Control and Prevention (CDC) guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. According to the guidelines, staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the CDC's guidelines Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multi Drug Resistant Organisms (MDRO), dated 04/02/2024, revealed enhanced barrier precautions (EBP) were infection control measures recommended by the CDC to reduce the spread of MDROs. Those precautions required staff to wear gowns and gloves during high contact resident care activities. According to the CDC, EBP applied to residents who were infected or colonized with an MDRO and to residents at higher risk for MDRO transmission.Review of a document provided by the facility from the CDC, dated 06/28/2024, revealed guidance on EBP. According to the document, EBPs were recommended to reduce the transmission of MDROs, including extended spectrum beta lactamase (ESBL) producing bacteria, particularly in healthcare settings. The document indicated the approach was important for residents known to be colonized or infected with MDROs. Review of the manufacturer's recommendations for the facility glucometers revealed the meter was to be cleaned and disinfected after use on each resident. Further review revealed the manufacturer's guidelines listed products with acceptable Environmental Protection Agency (EPA) numbers for disinfection of the glucometer, including the bleach wipes the facility used.Review of the facility's policy titled, Infection Prevention Manual for Long Term Care: Hand Hygiene, revised 01/2023, revealed the purpose of the policy was to reduce the risk of infection transmission through appropriate hand hygiene. The policy stated hand hygiene was the most important measure for preventing healthcare associated infections and required staff to wash hands when visibly soiled or contaminated. According to the policy, if hands were not visibly soiled alcohol-based hand rubs could be used.1 a. Observation on 02/15/2026 at 2:22 PM revealed the [NAME] Unit Manager (WUM) failed to perform hand hygiene before entering or after exiting R55's room.b. Observation on 02/16/2026 at 5:07 PM revealed the [NAME] Wing Unit Manager (WUM) failed to perform hand hygiene before or after touching R102's hearing assistive device. Further observation revealed the WUM immediately entered and exited R42's and R44's room but failed to perform hand hygiene. During the continuous observation, the WUM did not reach for the wall-mounted hand sanitizers, nor did she rub her hands together as she would need to if she used alcohol-based hand rub.c. Observation on 02/18/2026 at 11:17 AM revealed the WUM failed to use hand sanitizer while entering R26's room. Further observation revealed the WUM provided resident care to R26, then failed to use hand sanitizer when exiting R26's room. d. Observation on 02/19/2026 at 9:18 AM revealed the WUM failed to perform hand hygiene after replacing a used tray into the dirty cart from room [ROOM NUMBER]. Per observation, she immediately reached into her pocket, grabbed a pen and paper, wrote on the paper, and placed it back in her pocket. The WUM then went into room [ROOM NUMBER] without using hand sanitizer, exited the room with the tray, put the tray back, then reached for the paper and pen in her pocket again without using hand sanitizer.In an interview on 02/19/2026 at 9:28 AM, the WUM stated she had used hand sanitizer after she set down each tray. She further stated she believed she used hand sanitizer more often than what was needed. Per interview, when asked why she failed to use hand sanitizer before reaching into her pocket, the WUM stated she needed to write down which tray she had picked up. When asked if she saw that the action could cause cross contamination, the WUM did not reply. Review of the CDC's guidelines Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multi Drug Resistant Organisms (MDRO), dated 04/02/2024, revealed enhanced barrier precautions (EBP) were infection control measures recommended by the CDC to reduce the spread of MDROs. Those precautions required staff to wear gowns and gloves during high contact resident care activities. According to the CDC, EBP applied to residents who were infected or colonized with an MDRO and to residents at higher risk for MDRO transmission.d. Observation on 02/19/2026 at 9:22 AM revealed SRNA6 failed to perform hand hygiene while collecting meal trays from R35's and R94's room.In an immediate interview, SRNA6 stated he knew he should use hand sanitizer in and out of each resident's room, but he forgot because he was carrying a meal tray. He stated he should have used hand sanitizer after setting the tray down, but he failed to do so.Review of a document provided by the facility from the CDC, dated 06/28/2024, revealed guidance on EBP. According to the document, EBPs were recommended to reduce the transmission of MDROs, including extended spectrum beta lactamase (ESBL) producing bacteria, particularly in healthcare settings. The document indicated the approach was important for residents known to be colonized or infected with MDROs. 2. Review of an admission Record, found in R60's electronic medical record (EMR), revealed the facility admitted the resident on 08/07/2023 with diagnoses including stage 5 chronic kidney disease, debility, and extended spectrum beta lactamase (ESBL) in urine, an MDRO.Review of R60's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/05/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of R60's Nurse Progress Note, found in R60's EMR, revealed on 02/12/2026, Hospice discontinued R60's urinary catheter.Review of Orders, dated 02/15/2026 and found in R60's EMR, revealed the resident was placed on enhanced-barrier precautions (EBP) related to colonization/history of ESBL. Review of the Comprehensive Care Plan [CCP], found in R60's EMR, revealed the resident's CCP was revised on 01/27/2026. The care plan did not include enhanced-barrier precautions (EBP) goals or interventions to prevent the spread of infection related to the ESBL.Observation of R60's room on 02/15/2026 at 4:04 PM revealed there was no isolation signage posted on the outside of the resident's door to indicate the resident was under enhanced-barrier precautions (EBP), and R60 was diagnosed with an MDR in her urine. Continued observation revealed State Registered Nurse Aide (SRNA) 10 entered R60's room to answer a light. The resident asked to be changed. The SRNA entered the room but failed to don (put on) a gown before providing high-contact resident care. During an interview with R60 on 02/15/2026 at 4:14 PM, she stated SRNA10 helped her with adjusting her position, rearranging her bed linen, and providing a new under pad. She stated SRNA10 did not wear a gown when she provided her care. During an interview with SRNA10 on 02/15/2026 at 4:10 PM, she stated the resident was not in EBP. She stated the resident was currently under hospice care and that her urinary catheter had recently been removed; therefore, she stated the resident no longer needed additional precautions.Additional observation on 02/18/2026 at 8:31 AM revealed SRNA7 entered R60's room to provide direct care to the resident. The resident requested to be changed. SRNA7 put on gloves but failed to don a gown. SRNA7 removed his gloves while he exited the room; however, the SRNA did not perform hand hygiene.During an interview with SRNA7 on 02/18/2026 at 8:35 AM, he stated the only precaution he was aware of for R60 was that the resident was Hospice. He stated he had received infection control training but could not recall when. During additional interview with R60 on 02/16/2026 at 3:51 PM, she stated staff did not wear gowns and gloves when providing care. R60 stated she recently had a urinary tract infection and was aware she still had bacteria in her urine. Additionally, she stated she previously had a urinary catheter that was recently removed. She stated while the catheter was in place, staff usually wore gowns and gloves when providing direct care. However, she stated since the catheter was removed staff no longer wore gowns and gloves when providing her care. R60 stated she was concerned staff could spread infections to her and other residents when they failed to wear the proper PPE.During an interview with Licensed Practical Nurse (LPN) 6 on 02/18/2026 at 8:36 AM, she approached the State Survey Agency (SSA) Surveyor and stated she overheard the interview with SRNA7. She stated R60 did not require EBP because the resident's urinary catheter had been removed. She stated she was unaware the resident was colonized with an MDRO. She stated she was not provided with any updates on R60's precaution status or MDRO diagnosis information from the previous shift.During an interview with the Infection Preventionist (IP) on 02/15/2026 at 5:00 PM, she stated R60 had previously been placed on EBP while an indwelling urinary catheter was in place. The IP stated when the catheter was removed, the hospice provider discontinued the EBP order, and the resident was no longer maintained on precautions. She stated the resident was colonized with an MDRO but noted the resident's urologist indicated precautions were not required after catheter removal. The IP stated documentation supporting this determination would be provided; however, the documentation was never provided. When asked by the SSA Surveyor whether a resident colonized or infected with an MDRO should remain on EBP, the IP stated the resident should have remained on EBP. 3 a. Observation on 02/15/2026 at 4:25 PM of the East Wing's Dirty Utility Room revealed medical supplies were stored in the room with the dirty linen and trash. There were nine intravenous (IV) poles, two oxygen concentrators, several suction machines, and one bedside commode stored among open containers of trash and linen. b. Observation of the East Wing Shower Room on 02/15/2026 at 4:30 PM revealed multiple areas of fecal staining and several formed fecal deposits on the floor. During an interview with LPN4, the East Wing's Unit Manager on 02/15/2026 at 4:30 PM, she stated the fecal matter should have been cleaned immediately by the staff member caring for the resident at the time the incident occurred. She further stated no residents had received showers that day and indicated the fecal matter must have remained from the previous day. She stated fecal matter was an infection control concern and placed residents at risk for disease. She stated it was her expectation that staff cleaned the shower room after the resident showered. She also stated equipment and supplies should not be stored with soiled linen or trash in order to prevent cross contamination and reduce the risk of infection transmission. c. Observation on 02/17/2026 at 10:54 AM of the laundry room revealed there were no non-permeable gowns available to wear when handling contaminated laundry. Further observation revealed debris, dust, and lint buildup, as well as trash and multiple items on the floor near the sink and behind the washing machines.During an interview with the Environmental Services (EVS) Director on 02/17/2026 at 10:58 AM, he stated staff used a cloth apron when handling dirty linen. He stated the aprons were laundered daily. The EVS Director stated he did not have non-permeable PPE available for the staff to use when sorting linen. Review of the manufacturer's recommendations for the facility glucometers revealed the meter was to be cleaned and disinfected after use on each resident. Further review revealed the manufacturer's guidelines listed products with acceptable Environmental Protection Agency (EPA) numbers for disinfection of the glucometer, including the bleach wipes the facility used.4. Observation on 02/17/2026 at 9:07 AM revealed Licensed Practical Nurse (LPN) 5 tested Resident (R) 3's blood glucose via fingerstick and returned the glucometer to his bedside drawer without cleaning or disinfecting the glucometer. Per observation, LPN5 did not have a bleach wipe in R3's room with her.In an immediate interview, LPN5 stated she wiped the glucometer with an alcohol pad after use. She further stated no one had trained her on which wipes to use at the facility, although she recalled using bleach wipes on glucometers at a previous job.In an interview on 02/19/2026 at 9:59 AM, the Infection Preventionist (IP) stated staff was to use the bleach wipes stocked on the medication carts with a three-minute wet time. She further stated staff was supposed to get training on glucometer disinfection practices during orientation. The IP stated each resident who needed a glucometer had their own individual glucometer. Additionally, the IP stated it was still important for staff to disinfect between uses to prevent accidental cross contamination because someone could have reached in the drawer for some other reason and touched the glucometer.In an interview on 02/19/2026 at 11:25 AM, the WUM stated she expected nurses to clean and disinfect the glucometers with a bleach wipe after each use. She further stated an alcohol wipe would be ineffective against blood borne pathogens. The WUM stated she did not perform routine audits of glucometer use and disinfection but did an audit of glucometer strips being changed as required.In an interview on 02/19/2026 at 4:59 PM, the Director of Nursing (DON) stated staff was to disinfect glucometers with bleach wipes. In an interview on 02/19/2026 at 5:42 PM, the Administrator stated staff should use bleach wipes to clean glucometers after each use, even though each diabetic resident had their own glucometer.5. Observation on 02/18/2026 at 8:22 AM revealed the Social Service Director (SSD) was making rounds on residents and visiting them in their rooms. She entered R48's and R19's rooms without performing hand-hygiene. She hugged both residents and did not perform hand hygiene between resident contacts. Further observation revealed the SSD then entered R41's room, touched the resident and the resident's environment, exited the room, and again did not perform hand hygiene.During an interview with the SSD on 02/18/2026 at 8:25 AM, she stated she always used alcohol-based hand rub (ABHR) after contact with residents. She stated further, But if I didn't, I should have. The SSD stated it was important to follow infection control policies and procedures to prevent the spread of infection.During an interview with the Staff Development Coordinator (SDC) on 02/19/2026 at 3:49 PM, she stated she was responsible for coordinating monthly in-service education for facility staff. The SDC reported education was provided to all departments, including nursing, housekeeping, dietary, therapy, and ancillary staff, depending on the subject matter. The SDC stated she provided training on hand hygiene education, and enhanced barrier and isolation precaution education was planned but had not yet been completed during her tenure. The SDC stated infection control education during orientation was primarily conducted by the Infection Preventionist (IP). She stated it was her expectation staff followed their training and education to ensure infection control procedures were followed. She stated infection control was important to prevent the spread of disease.During an interview with the IP on 02/19/2026 at 9:59 AM, she stated she served as the facility's Infection Preventionist and reported the role involved multiple responsibilities affecting various departments. She stated the facility maintained an infection prevention and control program designed to address surveillance, prevention, and control of disease and infection that was consistent with CDC guidelines. The IP stated annual competency evaluations for nursing assistants were conducted each March and included hand hygiene education, review of precaution signage, and instruction on the meaning of color-coded precaution signs, including enhanced barrier, contact, and droplet precautions. The IP stated new employees received orientation packets that included infection control education, which had to be completed before working on the floor. The IP stated staff should be able to identify required precautions for enhanced barrier and transmission-based precaution rooms, and if uncertain, signage should guide them on required personal protective equipment (PPE) and the situations requiring their use.During continued interview with the IP on 02/19/2026 at 9:59 AM, when asked about observations of staff not performing hand hygiene, the IP stated additional education was needed and indicated some staff members were resistant to updated practices due to prior experience. The IP stated infection prevention requirements applied regardless of job title, and hand hygiene was the primary method to prevent transmission of infection. The IP stated she addressed issues when observed during her rounds, but she was frequently performing wound care duties while also serving in the infection prevention role. She further stated it was her expectation that all staff followed the facility's infection control policies and procedures to prevent the spread of disease to residents, staff, and visitors.During an interview with the Director of Nursing (DON) on 02/19/2026 at 5:11 PM, she stated staff members were expected to perform hand hygiene in accordance with facility practices. The DON further stated it was her expectation that all staff followed enhanced barrier precautions and transmission-based precautions as indicated, including proper donning (putting on) and doffing (removing) of personal protective equipment (PPE) in accordance with CDC guidelines. The DON stated signage posted on resident doors was intended to remind staff of the required precautions and the PPE required to be worn. She stated it was her expectation that staff followed the facility's infection prevention policies to help prevent the spread of infection among residents, visitors, and staff. During an interview with the Administrator on 02/19/2026 at 5:39 PM, he stated staff was expected to follow facility policies, including hand hygiene, use of personal protective equipment, and adherence to transmission-based and enhanced barrier precautions in accordance with signage and regulations. He stated the Infection Preventionist communicated which residents were on precautions during the daily leadership meetings to ensure staff awareness. The Administrator stated his overall expectation was that staff followed all facility policies to maintain a safe environment and to ensure the well-being of the residents.During a telephone interview with Medical Director on 02/18/2026 at 4:04 PM, he stated it was his expectation that all staff followed the facility's infection prevention and control policies and procedures to prevent the spread of infection and to ensure the safety and well-being of residents and staff.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure each resident's right to a safe, clean, comfortable and homelike environment by providing maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 11 of 25 sampled resident rooms, (Rooms 4, 25, 32, 34, 49, 50, 52, 53, 58, 60, and 67). Observation on 02/16/2026 and 02/18/2026 revealed the listed rooms had maintenance issues which included damaged drywall, damaged baseboards, cracked flooring, unpainted drywall patches, an air conditioner with a corroded grille containing a black substance, wall stains, and dirty floors and baseboards.In addition, observation on 02/15/2026 revealed 2 of 2 working shower rooms with cleanliness issues. The shower on the East Unit had fecal staining, fecal deposits, mold, and a soiled shower chair. The shower on the [NAME] Unit had mold and a dirty floor with dark stained grout lines. The findings include:Review of the facility's policy titled, Homelike Environment, dated 08/01/2013, revealed the facility was to provide residents with a safe, clean, comfortable, and homelike environment. Further review revealed the facility staff was to minimize the characteristics of the facility that reflected a depersonalized, institutional setting.1. Observation of the East Shower Room on 02/15/2026 at 4:30 PM revealed multiple areas of fecal staining and several formed fecal deposits on the floor. Red mold was observed in the shower area, and a single shower chair was visibly soiled.2. Observation of the [NAME] Shower Room on 02/15/2026 at 4:50 PM revealed mold around the base, faucet, and grab bars. The floor appeared dirty with dark-stained grout lines.3. Observation of room [ROOM NUMBER] on 02/16/2026 at 10:09 AM revealed a PTAC (Packaged Terminal Air Conditioner which was a self-contained unit that provided through-the-wall heating and cooling), unit with a front grille that was heavily rusted and corroded, with chipped and peeling paint and visible black grime and debris accumulated on and within the vent slats. The black substance was noted along multiple slats and within the interior of the grille openings. The buildup was visibly adhered to the surfaces surrounding the air discharge area.Review of the facility's Work History Report revealed on 04/30/2025, 07/31/2025, 10/31/2025, and 01/31/2026 maintenance staff documented cleaning air filters and inspecting condenser coils with cleaning performed as needed for PTAC systems. However, the documentation did not specify which individual PTAC units were serviced.4. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:10 PM revealed a large, dried food stain on the wall. There was dried food on the bed rail and the floor. Further observation revealed dirt and dried material consistent with food residue beneath the resident's fall mat, the floor was visibly dirty with multiple dark spill stains, and the baseboards were visibly soiled with dirt and dust.5. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:18 PM revealed the drywall around the paper towel holder was bare and damaged in the bathroom.6. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:21 PM revealed the baseboards were damaged, with splintering, exposed, raw wood.7. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:22 PM revealed the wall behind the A bed was damaged, with exposed drywall visible.8. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:24 PM revealed its walls had drywall patches that had not been painted over.9. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:37 PM revealed the ceiling was noted to have extensive brown water staining and discoloration across multiple areas, with visible deterioration of the ceiling surface. Further observation revealed a black discoloration of the baseboard on the left side of the bathroom and a newly replaced, raw wood baseboard on the back wall of the bathroom. Per observation, the linoleum had a hole missing out of it right in front of the commode and an exposed edge of the linoleum along the back wall, which had not been secured after the baseboard was replaced. Additionally, room [ROOM NUMBER] had a hole in the linoleum by Bed A.In an interview on 02/18/2026 at 2:38 PM, the resident that resided in room [ROOM NUMBER] stated the ceiling had water stains and cracks. Furthermore, she stated in the bathroom there was a large gash on the floor and rotted wood on the baseboard on the left side of the sink. She stated she had reported concerns regarding the condition of her room to staff and the Administrator. The resident stated these conditions made her feel anxious and concerned for her safety including fear of potential mold exposure and that the bathroom floor was a safety hazard.10. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:40 PM revealed the wall behind each bed was damaged with exposed drywall.11. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:46 PM revealed the flooring immediately inside the entrance was cracked and dented.12. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:48 PM revealed the wall behind Bed A was damaged with exposed drywall.13. Observation of room [ROOM NUMBER] on 02/18/2026 at 2:49 PM revealed the drywall around the paper towel holder was bare and damaged in the bathroom. Further observation revealed the trim at the top of the sink in the bathroom was damaged, leaving exposed raw wood open to the moisture in the room. Continued observation revealed a water stain on the ceiling in the bathroom.In an immediate interview with the resident residing in room [ROOM NUMBER] and the resident's family, they stated the facility told them they were going to refinish the floor in her room and remodel the bathroom. However, they stated the resident had been in the facility for 14 months, and they had never seen anyone fix the issues in her room. They stated they were disappointed the facility had not delivered on the promise to improve the resident's physical environment.In an interview on 02/18/2026 at 4:06 PM, Licensed Practical Nurse (LPN) 6 stated if she saw damage in a resident's room, she would put a maintenance request in the computer portal the maintenance department used. LPN6 was able to quickly access the portal but stated she had not put in any orders recently.In an interview with LPN4/ East Unit Manager (UM) on 02/19/2026 at 10:55 AM, she stated she was aware that repairs were needed in several rooms but could not speak to the condition of rooms [ROOM NUMBERS] specifically. She stated nursing staff notified her of issues such as damaged walls, baseboards, or water leaks, and she submitted work orders through the facility's maintenance request system computer portal. She further stated she had not personally put one in for the damages to the rooms on her unit. LPN4/UM stated repairs that required an extended time could only be completed when residents were temporarily relocated from the room, and that could be difficult, particularly when the facility was at full census. She stated safety-related repairs were addressed immediately. In an interview on 02/18/2026 at 5:00 PM while the Corporate Director of Plant Operations (CDPO) toured the damaged rooms with the State Survey Agency (SSA) Surveyors, he stated the physical environment was safe, functional, sanitary, and compliant with federal and state regulations. The CDPO stated the facility utilized a maintenance management system called TELS that documented maintenance requests and tracked pending repairs. Additionally, he stated maintenance repairs for walls, ceilings, floors, and baseboards were done through notification on the TELS system and were completed routinely as the room was vacant. He further stated maintenance staff routinely cleaned and changed filters on heating ventilation and air conditioning (HVAC) units and PTAC units. He stated baseboards had been ordered and would be replaced; however, he could not specify a date for completions. Additionally, the CDPO stated regular upkeep was important because the building itself directly affected resident safety, infection control, and quality of life. He further stated the facility management and regional team were aware repairs needed to be done, but the timeline was so long, they did not want to track it in the computer portal. The SSA Surveyors requested the separate log of tasks to be completed, but the facility failed to provide it prior to exit.In an interview on 02/19/2026 at 4:59 PM, the Director of Nursing (DON) stated she expected staff to enter requests for repairs, including holes in the walls and bathroom repairs, into the maintenance computer portal. She further stated she did not have access to track the items in the computer portal, so she did not know how many unfinished tasks were in there. She stated it was important to provide the residents with a homelike environment, but she did not believe the disrepair resulted in not having a homelike environment for those residents.In an interview on 02/19/2026 at 5:42 PM, the Administrator stated the repairs to the resident rooms had not been completed because they kept a full census by admitting new residents when beds became available instead of using the bed spaces to move residents around to complete repairs in their rooms. He stated there was a plan to maintain census at a lower level to allow temporary room vacancies for painting and flooring replacement. The Administrator stated he would not want to live in a home with damaged walls and floors, and he did not want the residents in his building to live in a sub-par facility. He stated repairs were important to maintain a homelike environment.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure appropriate storage of resident medications, with loose pills and undated medications found in 3 of 8 medication carts, East 1, [NAME] 1, and [NAME] 3, and 1 of 2 medication rooms, the East Wing.The findings include:Review of the facility's policy titled, Medication Storage in the Facility, dated [DATE], revealed the policy's purpose was to ensure that medications and biologicals were stored safely, securely and properly, and following manufacturer's recommendations or those of the supplier. Further review revealed all medications dispensed by the pharmacy were stored in containers with the pharmacy label. Continued review revealed medications in multi-dose packaging would have beyond-use dating per pharmacy protocol. Additional review revealed when the original seal of a manufacturer's container or vial was initially broken, the container would have a sticker on the medication with the date opened marked.1. Observation of the East 1 Medication Cart on [DATE] at 1:39 PM revealed Resident (R) 90's budesonide inhalation suspension 0.5 milligrams (mg)/2 milliliter (mL) opened with no opened date indicated and three loose vials were observed in the pouch. No opened date was documented on the box. Further observation revealed R90's Glutose 15 oral glucose gel 40 percent, 3.75 ounce, with an expiration date of [DATE], indicating the product had expired. Further observation revealed there were 14 loose pills in the drawers. 2. Observation of the [NAME] 1 Medication Cart on [DATE] at 1:51 PM revealed 17 loose pills in the cart.3. Observation the East Wing Medication Refrigerator on [DATE] at 2:03 PM revealed one vial of Tubersol (tuberculosis test solution) had been opened, with no opened date indicated on the bottle or box.4. Observation of the [NAME] 3 Medication Cart on [DATE] at 2:20 PM revealed seven loose pills, including vitamin D 50 micrograms (mcg); nifedipine (a calcium channel blocker used to treat high blood pressure and angina) 30 mg; famotidine (a histamine-2 blocker that reduced stomach acid) 20 mg; Buspar (used to treat anxiety) 5 mg; sertraline (an anti-depressant) 25 mg; sertraline 50 mg; and sacubitril-valsartan 24-26 mg (used to treat chronic heart failure). Further observation revealed R58's Spiriva 2.5 mg inhaler was opened, but there was no opened date recorded. Continued review revealed a house stock bottle of ProHeal, a liquid protein supplement, that was opened but undated.During an interview with Kentucky Medication Aide (KMA) 1 on [DATE] at 8:59 AM, she stated if she found loose pills or dropped one, she had to discard them and notify the nurse. She stated she always checked the cart to be sure it was clean. She stated ensuring pills were accounted for was safety promotion, so a resident did not take a pill not intended for them. During an interview with Licensed Practical Nurse (LPN) 5 on [DATE] on 9:14 AM, she stated if she dropped a pill, she must discard it. She stated it was important for safety because a resident could find it, pick it up, and take it. She stated if she did not find the pill on the floor, she must look for it in the drawers and discard it. She stated if it was a narcotic, she must notify the Director of Nursing (DON). She also stated the Unit Manager (UM) and Pharmacy were supposed to audit the carts periodically. During an interview with the East UM on [DATE] at 11:04 AM, she stated nurses were responsible for their medication cart. She stated if they opened eye drops or anything with multiple doses, they must date them, and they were expected to do so. She further stated nurses were responsible to be sure there were no loose pills in the cart, and if a loose pill was found, they must set it aside and notify the pharmacy. She stated upper leadership were responsible for certain carts and auditing them. She stated the loose pills found were a result of staff not taking the responsibility. During an interview with the [NAME] UM on [DATE] at 11:14 AM, she stated she and the nurses were responsible for maintaining the medication carts. She stated if a nurse or KMA dropped a pill, they were expected to find it at that time, discard it, and let the pharmacy know. She stated it was important to locate dropped pills because if on the floor, for example, a resident could find it and take it, making it a safety issue. She stated there should not be loose pills in the cart drawer, and staff could look in the area where the loose pill was found and identify the owner, which was important so it could be replaced and accounted for. She stated the audit process should capture that sort of thing. She stated she had seen a problem with that when the cart was overstocked. For example, she stated the resident received eight cards of Tylenol, so the excess cards were stored in the bottom drawer of the medication cart. She stated her expectation was for nurses to clean the cart after every shift's medication administration and that nurses would notify her of dropped pills. She stated she notified pharmacy, and they would send the dose for a replacement. She stated it was important to ensure no loose pills were in the medication cart because it could be misappropriation or diversion.During an interview with the Staff Development Coordinator (SDC) on [DATE] at 4:00 PM, she stated medication storage should be Nurse 101, the basics. She also stated it was not that hard to put the date on a medication when you opened it. She stated the action after popping a pill out of the card and losing it was to look for it and get a second pair of eyes to help find it. She stated it was a safety issue because if a resident saw the pill, they might think it was candy and be hurt by ingesting it. She also stated a nurse would notify pharmacy for replacement. She stated if pharmacy could not replace the pill due to insurance, then the facility would pay for it. She stated that it was information she gave to the staff during education. During an interview with the Director of Nursing (DON) on [DATE] at 4:40 PM, she stated she expected opened medications to be dated with the date they were opened. She also stated not checking dates could cause the residents to run out of medications, and it was necessary to timely notify the pharmacy for additional medications. She stated her expectation for the nurses/KMAs was that they did not overfill the drawers, to check if all residents had the medications they were supposed to have, and to keep the medication carts clean.During an interview with the Administrator on [DATE] at 5:39 PM, he stated nursing staff was expected to follow the facility's policy for medication labeling, storage, and disposal of medications, including appropriate handling of dropped medications. He stated medication management was important to ensure residents received ordered medications and to prevent diversion of resident property.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 sampled residents, Resident (R) 60.Review of R60's Order Summary Report, revealed on 01/21/2026 an active order for the resident to receive Hospice care. However, the facility failed to develop a care plan for R60 to include Hospice Care. The findings include:Review of the facility's policy titled, Care Plan Policy, dated 08/04/2024, revealed the facility would develop and implement a person-centered care plan for each resident to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Further review revealed the comprehensive care plan was to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the policy revealed licensed nurses and interdisciplinary teams developed and maintained the care plan for each resident.Review of an admission Record, for R60 revealed the facility admitted the resident on 08/07/2023 with diagnoses including stage 5 chronic kidney disease, and debility atrial fibrillation. The resident was admitted to Hospice care on 01/21/2026.Review of R60's quarterly Minimum Date Set [MDS], with an Assessment Reference Date (ARD) of 02/05/2026, revealed a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of an Order Summary Report, revealed on 01/21/2026, an active order admitted the resident to Hospice with the life expectancy of less than six months with the diagnosis of chronic kidney disease and heart failure.Review of the Comprehensive Care plan [CCP], revealed the resident's CCP was revised on 01/27/2026. However, the CCP did not include Hospice oriented goals or interventions to support end of life care.During an interview with R60 on 02/15/2026 at 3:51 PM, she stated she had been in and out of Hospice services and had recently resumed Hospice care. She stated she had not noticed any additional attention or changes in care since resuming Hospice and was unable to recall when hospice staff last visited.During continued interview with the MDS Coordinator on 02/19/2205 at 10:42 AM, the MDS Coordinator stated Hospice services focused on comfort measures and coordination with Hospice providers. She stated when a resident was placed on Hospice services, the care plan should be addressed to ensure comfort focused interventions were implemented. She further stated communication of the resident's Hospice status was important so staff could prioritize comfort. When asked why Hospice services were not reflected in the active care plan for R60, the MDS Coordinator stated she was aware of the issue but did not provide a specific explanation during the interview.During continued interview with the MDS Coordinator on 02/19/2026 at 10:42 AM, she stated her job duties included patient assessment, completion of baseline care plans, order review, and initiation of a resident's care plan. She further stated the facility used an interdisciplinary team approach when care plans were updated, and care plans were a work in progress. She stated new physician orders and changes in condition were reviewed daily during meetings, and care plans were updated as soon as possible following changes. The MDS Coordinator stated the purpose of the care plan was communication to staff of a resident's needs and potential problems. She further stated Hospice services should have been added to R60's care plan. During additional interview with the Director of Nursing (DON) on 02/19/2026 at 5:11 PM, she stated the resident care plan directed staff on how to meet each resident's needs and should be followed as written. The DON stated staff was expected to review the care plan before providing care, implementing the listed interventions to ensure the residents' safety and well-being. Additionally, the DON stated nurses, the MDS Coordinator, and the IDT were responsible for updating care plans when the residents' conditions changed. The DON stated her expectation was that all staff followed the care plan consistently to provide care in accordance with the residents' assessed needs.During an interview with the Administrator on 02/19/2026 at 5:39 PM, he stated he but expected staff to follow the facility's policies and rules. The Administrator stated the facility was responsible for ensuring all residents' needs were met and all received the same quality of care. He further stated he expected staff to follow all residents' care plans because care plans guided the residents' individualized care, preferences, and needs.During a telephone interview with the Medical Director on 02/18/2026 at 4:04 PM, he stated it was his expectation that a plan of care was established and followed to ensure the resident's needs were addressed.

Based on observation, interview, record review, review of the facility's policy and signage, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 4 of 42 sampled residents, Resident (R) 9, 19, 35, and 36. The findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines Infection Control Guidance: SARS-CoV-2, dated 06/24/2024, revealed adherence to infection prevention and control practices was essential to providing safe and high quality patient care across all settings where healthcare was delivered. Further review revealed facilities should limit movement of the resident outside of the room to medically essential purposes. Review of the CDC guidelines Healthcare Provider and Facility Operational Considerations, dated 08/06/2024, revealed the CDC recommended using precautions to prevent the spread of infection while performing aerosol-generating procedures (AGPs). The CDC recommended keeping the door closed during the procedure. Further review revealed the guideline stated the Covid-19 positive resident should be in a private room, if not then the roommate should be removed from the room during the procedure. Per the guideline, if the roommate could not be removed, the curtain should be drawn between the beds, and staff should increase ventilation by cracking a window or putting a fan face-out in the window. Review of the facility's policy titled, Covid-19, revised 12/05/2023, revealed in addition to standard precautions, special droplet and contact precautions would be implemented for residents suspected or confirmed to have Covid-19 based on the CDC guidance. The policy stated the facility would follow the CDC published guidance for residents with suspected Covid-19. Further review revealed, for procedures performed on residents with known or suspected Covid-19 that were likely to induce coughing (e.g., nebulizer treatments), staff was to refer to CDC guidance. Additionally, the policy stated residents in transmission based precautions (TBP) were restricted to the room except for medically necessary procedures. Per the policy, if the resident had to leave the room, he/she would be encouraged to wear a face mask or a cloth face covering. Review of the facility's signage Special Droplet/Contact Precautions (procedure to be used) revealed everyone must, including visitors, doctors, and staff, clean hands when entering and leaving the room, wear a facemask, eye protection, and gown and glove at the door. Further review of the signage revealed when doing aerosolizing procedures, a fit tested N-95 respirator with eye protection or higher was required. Additional review revealed to keep the door closed. Review of the facility's signage Sequence for Putting on Personal Protective Equipment (PPE) (procedure to be used), revealed the gown must fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. Review of the facility's signage How to Safely Remove PPE revealed to remove all PPE before exiting the patient room except a respirator was removed after leaving the resident's room. Further review revealed if the front of the mask/respirator was contaminated-DO NOT TOUCH. Additional review revealed if hands got contaminated during mask/respirator removal, immediately wash hands or use an alcohol-based sanitizer and discard in a waste container. Review of the facility's signage Enhanced Barrier Precautions (EBP) (procedure to be used) revealed everyone must clean hands before entering and leaving the room and wear gloves and a gown for High-Contact Resident Care Activities which included changing linens. 1. Observation on 08/13/2024 at 1:00 PM revealed State Registered Nurse Aide (SRNA) 1 entered an EBP room without donning (putting on) PPE. During an interview with SRNA1 on 08/13/2024 at 1:15 PM, she stated R9 spilled a soda on the top sheet, and she changed it. SRNA1 stated she had EBP training, and the training included to always wear a gown and gloves when providing care and to wash or sanitize hands. She stated R9 had a wound, but she did not think R9 was on EBP. Review of R9's Face Sheet revealed the facility admitted the resident on 02/21/2024 with diagnoses to include morbid obesity, methicillin resistant staphylococcus aureus infection (multi-drug resistant bacteria) as the cause of disease classified elsewhere, and high blood pressure. Review of R9's Physician's Orders, dated 06/30/2024, revealed an order for EBP. Additional review of an order, dated 05/29/2024, revealed an order for wound treatment to the left gluteus. Review of R9's Comprehensive Care Plan (CCP) with initiation date of 02/22/2024 and revision date of 08/08/2024, revealed a focus identifying R9 at risk for infection related to disease process and communal living situation. Additional review revealed interventions to include EBP with initiation date of 02/29/2024 and revision date of 08/08/2024 to include infection control per facility protocol. Continued review revealed additional interventions to include infection control per facility protocol. Further review revealed the left gluteal wound had resolved with initiation date of 05/29/2024 and resolved date of 06/01/2024. 2. Observation of the East Wing on 08/15/2024 at 1:45 PM revealed a clear plastic garbage bag full of dirty linens was on the floor in the hallway outside of room [ROOM NUMBER], a droplet precaution isolation room. During an interview with SRNA 8 on 08/15/2024 at 1:50 PM, she stated staff should bag dirty linen from a transmission-based precaution (TBP) room, take the bag to the dirty linen room, and place the bag in blue bags, indicating the linen was from an isolation room. SRNA8 stated staff should not place linen on the floor. She stated following infection control protocols was important to prevent the spread of infection and cross-contamination. During an interview with the Housekeeping Supervisor on 08/21/2024 at 9:40 AM, he stated laundry from isolation rooms were bagged in the room, and staff took contaminated laundry to the dirty utility room. He stated isolation laundry was placed in a blue biohazard bag and put in a laundry bin. He stated staff then took the bin to the laundry. He stated laundry personnel were trained to wash those items separately. He further stated it was important to separate laundry to prevent the spread of infection to residents. 3. a. Observation of the East Wing on 08/15/2024 at 1:45 PM revealed R19, a roommate of R36, who was Covid-19 positive and had been exposed to Covid-19, was seated in her wheelchair in the doorway to her room with a mask on. However, it was not covering her mouth and nose. R36 was unmasked, sitting in bed, and the privacy curtain was not closed. b. Observation of the East Wing on 08/19/2024 at 12:36 PM revealed R35 in room [ROOM NUMBER], who was Covid-19 positive, sitting halfway in the doorway and halfway in the hallway, not wearing a mask. Several staff members passed the resident while handing out meal trays, but none of them encouraged him to wear a mask or return to his room. During an interview with SRNA5 on 08/19/2024 12:45 PM, she stated residents with Covid-19 and in droplet isolation precautions should remain in their rooms. She stated if the resident was in the doorway they must wear a mask. SRNA5 stated she did not see R35 out of his room and if she had seen him, she would have redirected him back to his room. SRNA5 further stated following infection prevention and control practices (IPCP) was important to prevent the spread of infection and cross contamination. During an interview with SRNA8 on 08/19/2024 at 11:05 AM, she stated if a resident was in any TBP isolation other than EBP, they should remain in their rooms. She stated if they were near the doorway or needed to leave, they were redirected to wear a mask to prevent the spread of infection to other residents and staff. During an interview with Kentucky Medication Aide (KMA)/SRNA6 on 08/14/2024 at 2:25 PM, she stated residents with Covid-19 and in droplet isolation precautions should remain in their rooms. She stated if the resident was in the doorway they must wear a mask. KMA/SRNA6 stated she did not see R19 unmasked while sitting in the doorway. She stated if she had she would have redirected her to place the mask over her nose and mouth. During an interview with Licensed Practical Nurse (LPN) 5 on 08/14/2024 at 1:50 PM and on 08/18/2024 at 12:33 PM, she stated that Covid-19 residents should remain in their rooms. She stated if they were near the doorway or needed to leave, they must wear a mask. She further stated staff should encourage residents to wear masks. LPN5 stated following IPCP was important to prevent the spread of infection to at risk residents. During an interview with Registered Nurse (RN) 1 on 08/14/2024 at 2:40 PM, she stated according to facility policy, residents with Covid-19 should remain in their rooms. She stated if they were near the doorway or needed to leave the isolation room, they must wear a mask. During an interview with the Director of Nursing/Infection Preventionist (DON/IP) on 08/17/2024 at 12:07 PM, she stated according to policy, residents under droplet precaution isolation should stay in their rooms. She stated residents in droplet precautions who were sitting in their doorways or out of their room without a mask should be encouraged to wear a mask. She stated if the resident came out of the isolation room, they must wear a mask to prevent the spread of infection to other residents, staff, and visitors. 4. Observation of the East Wing on 08/15/2024 at 2:50 PM, revealed the door to room [ROOM NUMBER], a droplet precaution isolation room, was wide open. Upon further observation, R36, who tested positive for COVID-19 on 08/13/2024, was observed having a nebulizer treatment. R36 was in the bed near the window, and her privacy curtain was not pulled. R36's roommate, R19, who was not COVID-19 positive, was in her room sitting in her wheelchair near the door during R36's treatment. R19 was wearing a mask, however it was pulled down below her chin. No source control precautions were taken to minimize the spread of potential aerosolization. During an interview with LPN3 on 08/15/2024 at 2:55 PM, she stated she was not aware R36 was receiving a nebulizer treatment. She stated that to prevent the spread of infection, the privacy curtain and door should be closed. She stated, however, that most of the residents in droplet precaution isolation had requested their doors remain open. During an interview with the DON/IP on 08/15/2024 at 9:38 AM, she stated that doors and curtains remained open upon the request of the resident. She stated that according to CDC guidelines, doors and curtains should be closed to prevent the spread of Covid-19. However, she stated the resident had the right to have the door open. 5. Observation on 08/19/2024 at 1:35 PM revealed Housekeeper 2 entered rooms [ROOM NUMBER], removed garbage bags, and replaced each with a new one without donning gloves or practicing hand hygiene. Additional review revealed she took the bags of trash in each room with her and then walked up the hall to the dirty utility room to dispose of the bags. During an interview with Housekeeper 2 on 08/20/2024 at 11:20 AM, she stated she had been employed by the facility for about one year. When asked about entering rooms [ROOM NUMBER], she stated she was replacing garbage bags, and some were empty, and some had trash in them. She stated she was unsure if she wore gloves or not, but she had performed hand hygiene in the bathrooms of each room. During an interview with the Housekeeping Supervisor on 08/21/2024 at 9:55 AM, he stated Housekeeper 2 should have donned gloves prior to emptying garbage from resident rooms, and she told him she thought she had not performed HH because she was nervous since she knew the State Survey Agency (SSA) Surveyor was observing her. He stated it was important to wear gloves anytime staff was emptying garbage to prevent the spread of germs throughout the facility. 6. Observation on 08/19/2024 at 1:40 PM revealed SRNA4 donned PPE to enter a Covid positive room, room [ROOM NUMBER]. Additional review revealed SRNA4 donned one gown which did not fully cover the back side of her clothing. Further observation on 08/19/2024 at approximately 1:50 PM revealed SRNA4 exited the same room with an N-95 respirator on and an empty food tray in hand. Continued observation revealed SRNA4 sat the food tray on the floor in hallway outside of room [ROOM NUMBER]. He then removed the N-95 respirator and placed it in a tray, ungloved, without performing hand hygiene (HH) after the placement. Further observation revealed he then bagged both the N-95 respirator and food tray, carried them to the dirty utility room, exited the dirty utility room with the food tray unbagged, and placed it on the meal trolley. During an interview with SRNA4 on 08/19/2024 at 3:10 PM, he stated before entering a Covid positive room all PPE should be donned properly, and before exiting a Covid positive room all PPE should be removed and bagged. He stated he had infection control training by the Assistant Director of Nursing (ADON) and knew that process was important to keep anyone from getting sick. During an interview with the Director of Nursing (DON) on 08/22/2024 at 2:09 PM, she stated she had held the position since 07/03/2024 and was also the Infection Preventionist (IP) nurse. She stated if an isolation gown did not fully cover the staff's clothing, they should don two gowns. She stated HH should be practiced to prevent cross contamination, and if hands were visibly soiled, staff should wash hands. 44001 During an interview with the Assistant Director of Nursing (ADON) on 08/15/2024 at 2:05 PM, she stated the facility followed CDC guidelines for IPCP. She stated it was her expectation that all staff followed facility policies related to IPCP to include hand hygiene and wearing PPE. The ADON stated following infection control guidelines was important to prevent the spread of infection and cross contamination. During an interview with the DON/IP on 08/22/2024 at 2:08 PM, she stated her duties as DON/IP were to supervise all clinical staff to ensure they completed tasks to ensure the safety and well-being of all residents. She stated her expectation was that every employee followed facility protocols and procedures to ensure that residents were cared for and safe. The DON/IP stated the facility followed CDC guidelines and recommendations. She stated she educated staff immediately if there was a breach in infection control protocol. The DON/IP stated she did not conduct formal infection control audits of staff but stated, We do watch them. Per the interview, staff received infection control training upon hire, and it was reviewed many times throughout the year. She stated hand hygiene was essential to prevent the spread of infection. She stated it was her expectation that all staff performed hand hygiene before and after the care of residents by properly donning (putting on) and doffing (taking off) PPE per CDC guidelines. She stated following facility policies was important for the safety and well-being of residents and staff and to prevent the spread of infection and disease. During an interview with the Advanced Practice Registered Nurse provider on 08/17/2024 at 11:25 AM, she stated it was her expectation that staff followed provider orders related to TBP. She stated following IPCP was important to prevent the spread of infection and cross contamination. During an interview with the Interim Administrator 08/22/2024 at 2:32 PM, she stated her current job duties involved managing facility operations in all departments, including nursing. She emphasized the importance of resident safety, which was maintained through training, education, drills, testing, and quizzes. The Interim Administrator stated there was a need for continuous staff re-education and her expectation that all staff followed facility policy and IPCP. She stated nursing leadership should promptly correct breaches in infection control. She stated the facility had a 12-month rolling training program, and the DON/IP educated and audited staff regarding IPCP. The Interim Administrator stated it was her expectation for all staff to follow the facility's IPCPs, which was crucial to protect staff, residents, and visitors from infection and disease. During an interview with the Regional [NAME] President of Operations (RVPO) on 08/22/2024 at 2:45 PM, she stated that it was her responsibility to oversee the administration of operations. She stated it was her expectation for all staff to follow the facility's policies related to infection control and to maintain and adhere to IPCP in order to prevent the spread of disease.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to have an effective system in place to ensure residents who exhibited wandering behaviors or were assessed at risk for elopement received adequate supervision and monitoring for 1 of 10 sampled residents, Resident (R) 1. On 07/22//2024, R1 was ordered to be on 15 minute checks by the Advanced Practice Nurse Practitioner (APRN)1 due to the resident's diagnosis of dementia, high elopement risk, and history with falls. However, the order was discontinued on 07/30/2024, and the APRN1 stated she did not order the 15 minute checks to be discontinued. Therefore, on 08/02/2024 at approximately 2:00 PM, R1 exited the facility without staff knowledge, unsupervised, and unescorted. Interviews revealed the resident walked with a cane and shuffled, but was able to walk approximately 60 to 70 feet from the facility close to a two lane road. The resident was found on his knees. Per interviews, an alarm sounded to signal to staff the resident had exited the facility; however, staff failed to respond to the alarm in a timely manner. The findings include: Review of the facility's policy titled, Elopement Wander Risk Protocol, revision date 02/2023, revealed every resident would have an Elopement Risk Assessment completed on admission, quarterly, and whenever the resident experienced a significant change in status. Additional review revealed residents who were identified as risk for elopement would have interventions put in place to minimize such risk. Further review revealed residents who actually did attempt to leave the building unauthorized would be monitored every 15 minutes for 24 hours following the elopement attempt. Review of R1's Face Sheet revealed the facility admitted the resident on 02/23/2021 with diagnoses to include psychotic disorder with hallucinations, Alzheimer's, and history of falls and muscle weakness. Review of R1's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/17/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero-zero (00) out of 15, which indicated the resident was severely cognitively impaired. Review of R1's Elopement Risk Assessment, dated 02/15/2024, revealed R1 did not score as an elopement risk as evidenced by only yes to was the resident physically able to leave the facility on own with or without an assistive device. Review of R1's Elopement Risk Assessment, dated 05/17/2024, revealed R1 scored as an elopement risk as evidenced by answering yes to physically able to leave facility on own with or without assistive device and yes to does resident wander in an exit seeking manner. Review of R1's Fall Risk Assessment scored him as a high fall risk on 12/04/2023, 02/15/2024, 05/17/2024, and 08/14/2024. Review of R1's Order Set, dated 05/28/2024, revealed an order for Wander Guard/Wander Elopement Device due to poor safety awareness and to update the order with the new date when the bracelet was changed. Review R1's Order Set, dated 07/30/2024, revealed the resident's 15 minute checks were discontinued. Review of R1's Comprehensive Care Plan (CCP), dated 08/22/2022, revealed a focus of at risk for complications and or injury related to behaviors and history of wandering with revision date of 07/22/2024. Continued review revealed a focus of resident liked to wander and was at risk for elopement, date initiated 03/09/2021 with revision date of 12/18/2023. Review of interventions included 15 minute checks and if exit seeking offer snack or diversional activity, with initiation date of 08/02/2024. Further review revealed interventions included to allow resident to wander through out the facility with supervision as needed, initiated on 03/09/2021 without revision date noted. Review of R1's Progress Note, dated 07/30/2024 at 10:01 AM and 11:38 AM, revealed the nurse documented that 15 minute checks were discontinued today by the Unit Manager. Review of R1's Progress Note, dated 08/02/2024, and signed on 08/08/2024, by the Advanced Practice Registered Nurse (APRN) 1, revealed R1 was being seen for increased agitation behavior and exit seeking behaviors. Additional review revealed R1 was not followed with psychiatric services for multiple psychiatric diagnoses including poor safety awareness with impulsiveness, likely due to progressive dementia and continuing decline in cognition. Per the note, since R1 was at high risk for elopement, the plan was to continue with 15 minute checks per facility protocol, referrals to facilities with locked memory care units, consult psychiatric services at next facility visit, and Wander Guard bracelet for increased safety when wandering. Review of R1's Frequent Check Flow Sheet revealed 15 minute checks were initiated on 07/22/2024 at 8:00 PM and discontinued on 07/30/2024 at 10:15 AM. Further review revealed 15 minute checks were initiated on 08/02/2024 at 2:00 PM, with no documentation noted after 08/15/2024 at 9:00 AM. Observation on 08/13/2024 at approximately 2:30 PM revealed the area where R1 was found by staff was approximately 60 to 70 feet from the emergency egress door where he exited. Additional observation, on 08/15/2024 at 1:00 PM, revealed the area where R1 was found was approximately 70 feet from a two lane road. Observation on 08/14/2024 at 10:45 AM revealed R1 walking from the bathroom toward the bed with assistance of staff with slow, unsteady, shuffle like gait with a Wander Guard bracelet to his left wrist. Observation on 08/16/2024 at 10:05 AM revealed a Wander guard bracelet to R1's right ankle. During an interview with the East Hall Unit Manager (UM) on 08/13/2024 at 2:55 PM, she stated R1 had exited the facility on 08/02/2024, she thought around 2:00 PM or 2:30 PM. She stated R1 had always had the behavior of going from unit to unit, adding he at times would voice wanting to go home. During an interview with Housekeeper (HK) 1 on 08/13/2024 at 1:20 PM, she stated she had been in a resident room approximately halfway down the [NAME] Hall past the nurses' station, and upon exiting the room, she heard a door alarm at the end of the [NAME] Hall. She stated she walked to the [NAME] Hall nurses' station, which was located between the door alarming and where she had been cleaning. She stated as she approached the station, Registered Nurse (RN) 1 was sitting at the nurses' station on the computer. She stated she asked RN1 if she heard the alarm, and then they both walked toward the sounding alarm which was an emergency egress door at the end of [NAME] Hall. She stated as they approached the door, they could see out the sunroom's windows that R1 was in a grassy area, down on one knee in front of the facility. She stated she had seen R1 earlier in the day walking around on [NAME] Hall, adding he lived on East Hall, but that was not unusual for him. She stated she asked R1 where he was going once getting outside to him, and R1 stated, I am going home. During an interview with RN1 on 08/13/2024 at 1:50 PM, she stated she was sitting at the nurses' station when HK1 came to the area and asked if she heard the alarm. She stated she and HK1 starting walking down the [NAME] Hall where the emergency egress door was alarming. She stated as they approached the door, they could see (through the sun room windows) R1 out in the grassy area in front of the facility, down on one knee. She stated they both then went to the resident, and she assessed him and found no injuries. She stated she, HK1, and R1 returned through the facility's front door. She stated, when asked if she had heard the emergency egress door alarming, she was not sure. In an interview with State Registered Nurse Aide (SRNA) 7 on 08/14/2024 at 12:05 PM, she stated R1 usually had the behavior of always walking around a lot and being confused. She stated she thought R1 had a one-to-one sitter with him on second shift but not on day shift. She stated staff just kept an eye on him. She stated when R1 wandered around the facility she would re-direct him or offer snacks and that would help most of the time. During an interview with Licensed Practical Nurse (LPN) 5 on 08/14/2024 at 1:43 PM, she stated R1 could walk as long as he had his cane. She stated she felt his confusion had worsened over the last month or so and was asking staff how do I get out of here. She stated nurses did not update care plans or add interventions, nor did she look at care plans each day. She stated R1 had been on 15 minute checks due to an altercation with his roommate but was unable to state the exact date. She stated the day he exited the building she could not remember any different behavior. During an interview with Kentucky Medication Aide (KMA)/SRNA3 on 08/14/2024 at 2:25 PM, she stated R1 was either wandering through out the facility all day going to the doors, or going in and out of other resident rooms, or sleeping all day. She stated she was in another resident room at the time of the incident. During an interview with SRNA12 on 08/19/2024 at 10:35 AM, she stated R1 was usually disoriented and wandered up and down the hallways and would go to the doors and try to open, but he had always had that behavior. During an interview with the [NAME] Unit Manager on 08/22/2024 at 10:25 AM, she stated she was in a meeting in the conference room with other staff members the day R1 left the facility but was unable to name the others in the meeting. She stated she heard the alarm sound, but she nor anyone else in the conference room responded. She stated alarms were sounding all the time, and she felt like staff was just numb to it. She stated even if staff was numb to all the alarms, her expectation was to respond immediately. During an interview with the Maintenance Director on 08/15/2024 at 9:15 AM, he stated he was working the day R1 had left the facility but could not recall if he heard the alarm. He stated he had performed the door checks and Wander Guard checks the day of the incident, and they all worked. During an interview with the DON on 08/16/2024 at 10:30 AM, she stated she was working the day R1 left the facility, and he was outside without an escort or staff. She stated she was unsure how long R1 had been outside but thought it was about five minutes or so. She stated she would be concerned for a resident's welfare and safety of being outside alone and was aware the highway was close to the facility. Further, she stated she did not investigate the resident's leaving the facility without supervision as the resident remained on the facility's property. During an interview with the DON on 08/22/2024 at 2:09 PM, she stated her expectation was for staff to follow policies to assure the safety of all residents. During an interview with APRN1 on 08/16/2024 at 11:30 AM, she stated she did not order the 15 minute checks for R1 to be discontinued on 07/30/2024. She stated R1 was a high elopement risk and discussions were held in the IDT meetings. She stated she was unable to say when the last meeting was or if there were any resolutions. When asked what concerns did she have when she learned of R1 leaving the facility, she stated his safety due to history of dementia and falls. During an interview with the Administrator on 08/16/2024 at 12:45 PM, she stated she was acting interim Administrator and had started after the incident. She stated her expectations of staff was to respond to door alarms immediately, and it was the staff's responsibility to know the signs of exit seeking behavior. She stated her expectations was that staff provided supervision of the residents. She stated staff should not rely totally on alarms. In an interview with the Regional [NAME] President of Operations on 08/22/2024 at 2:45 PM, she stated her expectations were for staff to respond immediately to any alarm as soon as they heard it.

Based on observation, interview, review of facility policy, and record reviews it was determined the facility failed to have a system in place to adapt visitation policies according to current state and federal regulations allowing residents the right to receive visitors at the time of his or her choosing for for four (4) of twenty-two (22) sampled residents, Residents #2, #15, #16, and #18. The findings include: Review of the facility's policy titled, Visitation Policy During COVID-19 Pandemic, no date, revealed the facility would allow for visitation during the COVID-19 pandemic for residents to uphold their emotional and mental well-being. Further review revealed the facility would adhere to state and federal recommendations for visitation during the coronavirus outbreak. Review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, revised 03/10/2021, revealed it provided guidance regarding nursing homes reopening to State and Local Officials. Per guidelines, CMS allowed States to choose how recommendation guidelines were implemented. Further review revealed States could relax restrictions in nursing homes based on the following factors: 1) Case status in community; 2) Case status in the nursing home(s); 3) Adequate staffing; and 4) Access to adequate testing. Review of CMS Nursing Home Visitation - COVID-19, QSO-20-39-NH, revised 04/27/21, revealed visitation could be conducted through different means based on a facility's structure and residents' needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations. Furthermore, per CMS guidelines, Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios included limiting indoor visitation for unvaccinated residents, if the nursing home's COVID-19 county positivity rate was greater than ten (10) percent and less than seventy (70) percent of residents in the facility were fully vaccinated; residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they had met the criteria to discontinue Transmission-Based Precautions; or residents in quarantine, whether vaccinated or unvaccinated, until they had met criteria for release from quarantine. Review of the Kentucky's Cabinet for Health and Family Services (CHFS) Provider Guidance Update: Phased Reduction of Restrictions for Long Term Care Facilities memo, dated 05/13/2021, revealed the memo provided guidance in accordance with CMS's QSO-20-30-NH and QSO-20-39-NH recommendations regarding a phased approach to resuming currently suspended or limited services. Additionally, the memo stated, Through a person-centered approach, a Provider should work with the resident, family members or representatives, caregivers and the Ombudsman program to identify the need for a compassionate care visit. Compassionate Care visits were not limited to end-of-life situations and could include newly admitted residents in need of physical family support due to a sudden change in environment. Per review, the intent of the CHFS memo was to provide clarification to long-term care providers concerning the resumption of indoor and outdoor on-site visiting, effective 05/13/2021. Review of the Kentucky COVID-19 Daily Case Incidence Rate Map, dated 06/14/2021, revealed the positivity rate for [NAME] County, Kentucky (where the facility was located) was 3.9 percent. Review of the Porch Visitation Schedule revealed, between 03/16/2021 and 05/09/2021, residents were offered seven (7), thirty (30) minute appointment openings every Tuesday and Friday between the hours of 10:00 AM and 4:00 PM, with a lunch break from 12:00 PM to 1:15 PM. The 2:15 PM and 2:45 PM appointments were scheduled at fifteen (15) minute intervals. On Saturday and Sunday, there were four (4), thirty (30) minute appointment openings available between 3:15 PM and 6:00 PM. There was no indication on the schedule of visit location. Additionally, there was no documentation provided by the facility for 05/09/2021 through 05/24/2021. Beginning 06/08/2021 through 06/20/2021, the visitation schedule offered residents fourteen (14), thirty (30) minute appointment openings on Tuesday, Wednesday, and Friday between the hours of 10:00 AM and 4:00 PM, with a lunch break from 12:00 PM to 1:30 PM. Visit locations included the Breakroom and Lobby. The 2:15 PM appointment was designated in the Beauty Shop. Visits were not offered on Saturday. Residents were offered four (4), thirty (30) minute appointment openings every Sunday, between 3:15 PM and 6:00 PM. Visit locations on Sunday were in the Breakroom and Lobby. Review of the text log notifying families of indoor visits was sent by the Administrator on 03/12/2021. Per review, the message was delivered to ninety-three (93) phone numbers. Per the log, there were no reply messages. Furthermore, the facility could not provide documentation of any communication regarding any changes in visitations since the 03/12/2021 text notification. 1. Interview with Resident #15, on 6/15/2021 at 2:05 PM, revealed he/she had been fully vaccinated, and his/her only concern was the facility was not allowing visitors, except by appointment. He/she stated, Many of us miss our family. Resident #15 further stated his/her roommate missed his/her grandchildren who used to visit all the time, but he/she had not seen family in over one (1) year due to COVID-19. The resident also stated visitors could only come in once a week, and he/she went out to dinner with his/her fully vaccinated daughter last week. Review of Resident #15's medical record revealed he/she had a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. 2. Interview with Resident #16, on 06/15/2021 at 2:15 PM, revealed he/she missed frequent visits from family. The resident stated it had been a long time since he/she had seen his/her grandchildren. The resident said when he/she thought about when he/she would see them again, it made him/her very sad. Review of Resident #16's medical record revealed he/she had a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. 3. Observation of Resident #2, on 06/16/2021 at 12:00 PM, revealed the resident was sitting in a wheelchair with head downcast. When the State Survey Agency (SSA) Surveyor asked how he was doing, he replied that everything was ok, but he/she missed his/her spouse. Per interview, Resident #2 stated his spouse came to visit, but he/she would like the spouse and son to come more often. In addition, Resident #2 stated both the spouse and son lived in the same town as the facility, and he/she did not know the reason why his/her family did not visit more often. Review of Resident #2's medical record revealed he/she was admitted on [DATE] and had a BIMS score of three (3) of fifteen (15), indicating the resident had severe cognitive impairment. Telephone interview with Resident #2's spouse, on 06/16/2021 at 1:19 PM, revealed he/she was unaware of any changes to the facility's visitation policy. Per interview, Resident #2's spouse stated the couple had been married for fifty-nine (59) years, and he/she missed him terribly. When questioned if he/she visited Resident #2 often, he/she responded, No, only once a week. The spouse stated the facility would only allow one (1) thirty (30) minute visit per resident, per week. In addition, the spouse stated, if allowed, he/she would visit every day. Telephone interview with Resident #2's son, on 06/16/2021 at 3:55 PM, revealed Resident #2's family was allowed one thirty (30) minute visit, once a week, and if he brought the other parent, they had to split the time into fifteen (15) minute segments, because only one (1) person was allowed at a time. Per interview, Resident #2's son stated all family visits must be scheduled in advance through the activities department. He explained some weeks the facility could not accommodate every requested visitation. Resident #2's son stated the facility was under strict visitation rules due to the governor's regulations related to COVID-19 restrictions to ensure the safety of all the residents. He stated the restrictions had been very difficult on his family, and it had taken an emotional toll on his parents. 4. Interview with Resident #18, Resident Council President, on 06/16/2021 at 2:25 PM, revealed he/she had not presided over a Resident Council meeting in over one (1) year, due to COVID-19. He/she further stated that residents' visits with family were very limited. Resident #18 stated she did not get to see his/her daughter as much as he/she would like. Resident #18 stated he/she and other residents got lonely without visits. Review of Resident #18's medical record revealed he/she had a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Telephone interview with Resident #18's daughter, on 06/17/2021 at 2:18 PM, revealed she was unaware of any update regarding visitation. When asked if she had received a text, or letter regarding a visitation update several weeks ago, she replied, No, I don't think so. When asked if she received a text message on March 12, 2021 regarding changes to visitation restrictions, she replied, No, I haven't. Further interview revealed she had not received a letter informing her family of any policy changes. She stated she did speak to the Administrator recently about taking her parent to a funeral. When questioned if the Administrator updated her on recent changes regarding visitation at the time of their conversation, the daughter indicated she asked but was told nothing had changed. In addition she stated she was unable to visit her parent as often as she was able to because of COVID-19. Further, she stated she was allowed a thirty (30) minute visit one (1) to two (2) times a week if there were any open visitation slots available. Continued interview revealed she called the Activities Director to schedule her visits in advance. Resident #18's daughter expressed she did not want to ask permission to see her parent, and stated, I feel residents need their family visits. Additionally, Resident #18's daughter stated that the Administrator informed her that visits were limited due to the virus. Furthermore, she stated when she asked why the facility was not following the Governor's guidelines, the Administrator informed her that the facility followed federal mandates, not the State of Kentucky's phased reduction of restrictions on visitation. Interview with the Infection Preventionist (IP), on 06/16/2021 at 2:10 PM, revealed there were no active COVID-19 cases in the facility; there had been a facility outbreak in November and December 2020. She was unable to provide the approximate number of residents and staff who tested positive for COVID-19. She stated the COVID-19 vaccination was offered to staff and residents and believed the majority of staff and residents were vaccinated. She stated all staff and visitors were screened upon entry. Visitors used the front lobby entrance and were screened by front office staff. Per interview, it was her understanding that the facility followed state regulations regarding nursing home visitations. The IP did not know the current county positivity rate. Continued interview revealed the Activities Department was responsible for scheduling and facilitating all visitations. She stated all visitors and residents must wear masks and follow social distancing requirements. Furthermore, the IP said residents were discouraged from social excursions outside the facility but residents had the right to leave. Interview with the Activities Director (AD), on 06/16/2021 at 1:41 PM, revealed the activities department had been the point of contact for many of the residents' families because she scheduled all visits. The AD stated visitations were scheduled on certain days and times. Further interview revealed residents were allowed one (1) thirty (30) minute visit per resident, per week. She confirmed the resident may only have one (1) visitor at a time, so she suggested family members divide the time into two (2) fifteen (15) minute segments. She reported the facility used the staff break room and front porch for visits, and residents and visitors must social distance during the visit. Additional interview with the AD, on 06/16/2021 at 5:18 PM, revealed the Activities Department was responsible for scheduling and managing visitations. She stated the visitation schedule coincided with her work schedule to ensure she could facilitate all visits, while still performing her duties as AD. When asked if anyone else could facilitate visits, she stated, Yes. Review of the visitation schedule revealed blanks and blacked out slots. The AD stated both indicated no visits were scheduled for that time slot. Continued interview revealed residents were allowed one (1) visitor for thirty (30) minutes once per week; however, if a resident had two (2) visitors, the visit could be divided into two (2) fifteen (15) minute visits. Per interview families were not allowed to have more than one (1) visit per week, unless there were openings on the schedule or in an end-of-life situation. Visits were set up in the break room and on the front porch, weather permitting. Per interview, the AD stated, I wish more visits were allowed because they make the residents so happy. Further interview revealed the visitation scheduled was not mandated by the facility's ability to keep the residents safe but as a matter of convenience to accommodate staff schedules. The AD stated she was unacquainted with which regulations the visitation policy was based on, but stated she had read the Governor's 05/13/2021 updates. Additional interview revealed that many families would call to schedule a visit, and during these calls, the AD stated family members would voice their dissatisfaction with the facility's visitation. She stated many had asked why the facility continued to have such strict restrictions, even though state regulations had eased up. She stated she would tell family members the facility was following federal, not state, regulations. According to the AD, she was not aware the facility had a revised visitation policy effective 06/01/2021. Furthermore, she stated she was not aware of any communication updating residents and families of a new visitation policy. Interview with the Interim Director of Nursing (IDON), on 06/16/2021 at 4:29 PM, revealed that a new visitation policy was in effect, but she was unaware of the exact date it was implemented. She further indicated she did not have a copy of the policy and that the only copy was on the Administrator's computer, and she was unable to access the policy now. She stated while she did not know the specific days and times visitations were allowed, she did know the facility had added additional days and hours to the visitation schedule and was allowing more locations for visits in the lobby sitting room and courtyard. She stated the Activities Department was responsible for managing and scheduling all visitation. The IDON was unable to provide information regarding which state or federal regulations were applied to develop the facility's current visitation policy and that the Corporate Office developed the policy. Additional interview with the IDON, on 06/17/2021 at 10:50 AM and 12:20 PM, revealed she was not aware if the visitation policy provided to the State Survey Agency (SSA) Surveyor, on 06/16/2021, was the current policy, but would call the Administrator to confirm. The SSA Surveyor requested to see a visitor log, however, the IDON stated she did not think a visitor log was kept. The IDON stated she believed communication regarding the Visitation Policy update was sent via text message to the resident's responsible party, and residents were updated through Resident Council meetings. She also stated families could receive important policy changes by mail, and a copy of the Visitation Policy was kept in a binder in the front lobby for anyone to review. She stated the updated policy allowed for more times and locations. She believed the current locations being used for visitations were the breakroom, front porch, lobby, and courtyard. Per interview, the IDON stated others could check visitors in, but the Activities Department managed visits. She stated visitations were scheduled around the AD's schedule to ensure a staff member was available to accommodate visits. Telephone interview with the Administrator, on 06/17/2021 at 2:30 PM, revealed it was her understanding that the corporate office was using the Centers for Medicare and Medicaid Services (CMS) guidance, as well as recommendations from the Centers for Disease Control and Prevention (CDC) and Kentucky Association of Health Care Facilities (KAHCF) when considering visitors in the facility. The Administrator stated the visitation policy given to the SSA Surveyor, on 06/17/2021, was effective on 06/01/2021. She stated that not much was changed in the new update. Per interview, she stated the Activities Department managed visits; however, she and other staff had facilitated visits at times other than what was available on the Visitation Schedule. She stated visitations were scheduled around the AD's schedule to ensure staff was available to accommodate visitors. Continued interview with the Administrator, on 06/17/2021 at 2:30 PM, revealed she stated she was surprised that SSA Surveyors were concerned about how many visits residents got, as she thought the Office of Inspector General (OIG) would be concerned the facility allowed too many visits. The Administrator stated she informed residents and families about policy changes and changes in facility operations frequently through text messages. When asked to clarify that all responsible parties had asked to be notified by text, instead of by mail, she stated, Yes. Continued interview revealed the last text communication sent to families regarding resident visitation was dated 03/12/2021. When questioned how families and residents had been informed regarding the 06/01/2021 updated policy, she replied that a copy was kept in the front lobby, and those that called or visited were made aware of policy changes. Post exit interview with the Administrator, on 06/23/2021 at 4:05 PM, revealed she was not familiar with updated recommendations provided in Kentucky's CHFS Provider Guidance Update: Phased Reduction of Restrictions for Long Term Care Facilities, or CMS's Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH memos. She revealed the facility had opened up more locations for visitations, including the breakroom, front porch, lobby, and courtyard.

Based on observations, interviews, review of facility policy, and record reviews it was determined the facility failed to inform each resident (or resident representative, where appropriate) of his/her visitation rights when facility policy and procedures were updated due to COVID-19 visitation restrictions. Including any clinical or safety restriction or limitation on such rights, and to whom the restrictions apply, when he/she was informed of his or her other rights, for four (4) of twenty-two (22) sampled residents: Residents #2, #15, #16, and #18. The findings include: Review of the facility policy titled Visitation Policy During COVID-19 Pandemic, no date, revealed the facility would allow for visitation during the COVID-19 pandemic for resident to uphold their emotional and mental well-being. Further review revealed the facility would adhere to state and federal recommendations for visitation during the coronavirus outbreak. Review of the Center for Medicare and Medicaid Services (CMS) Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, revised 03/10/2021, revealed it provided guidance regarding nursing homes reopening to State and Local Officials. Per guidelines, CMS allowed States to choose how recommendation guidelines were implemented. Further review revealed States could relax restrictions in nursing homes based on the following factors: 1) Case status in community; 2) Case status in the nursing home(s); 3) Adequate staffing; and 4) Access to adequate testing. Review of CMS Nursing Home Visitation - COVID-19, QSO-20-39-NH, revised 04/27/21, revealed visitation can be conducted through different means based on a facility's structure and residents' needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations. Furthermore, per CMS guidelines, Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. Additionally, a nursing home must facilitate in-person visitation consistent with the applicable CMS regulations; and, facilities shall not restrict visitation without a reasonable clinical or safety cause. Review of the Cabinet for Health and Family Services (CHFS) Provider Guidance Update: Phased Reduction of Restrictions for Long Term Care Facilities memo, dated 05/13/2021, revealed the memo provided guidance in accordance with CMS's QSO-20-30-NH, and QSO-20-39-NH recommendations regarding a phased approach to resuming currently suspended or limited services. Additionally, Through a person-centered approach, a Provider should work with the resident, family members or representatives, caregivers and the Ombudsman program to identify the need for a compassionate care visit. Compassionate Care visits were not limited to end-of-life situations, and could include newly admitted residents in need of physical family support due to a sudden change in environment. Per review, the intent was to provide clarification to long-term care providers concerning the resumption of indoor and outdoor on-site visiting effective 05/13/2021. Review of the COVID-19 Daily Case Incidence Rate Map, dated 06/14/2021, revealed the positivity rate for the facility's county was 3.9 percent. Review of the Porch Visitation Schedule, revealed between 03/16/2021 and 05/09/2021, residents were offered seven (7), thirty (30) minute appointment openings every Tuesday and Friday between the hours of 10:00 AM and 4:00 PM, with a lunch break from 12:00 PM to 1:15 PM. The 2:15 PM and 2:45 PM appointments were scheduled at fifteen (15) minute intervals. On Saturday and Sunday, there were four (4), thirty (30) minute appointment openings available between 3:15 PM and 6:00 PM. There was no indication on the schedule of visit location. Additionally, there was no documentation provided by the facility for 05/09/2021 through 05/24/2021. Beginning 06/08/2021 through 06/20/2021, the visitation schedule offered residents fourteen (14), thirty (30) minute appointment openings on Tuesday, Wednesday, and Friday between the hours of 10:00 AM and 4:00 PM, with a lunch break from 12:00 PM to 1:30 PM. Visit locations included the Breakroom and Lobby. The 2:15 PM appointment was designated in the Beauty Shop. Visits were not offered on Saturday. Residents were offered four (4), thirty (30) minute appointment openings every Sunday, between 3:15 PM and 6:00 PM. Visit locations on Sunday were in the Breakroom and Lobby. Review of the text log notifying families of indoor visits was sent by the Administrator on 03/12/2021. Per review, the message was delivered to ninety-three (93) phone numbers. Per the log, there were no reply messages. Furthermore, the facility could not provide documentation of any communication with families or residents regarding any changes in visitations since the 03/12/2021 text notification. Interview with Resident #15, on 6/15/2021 at 2:05 PM, revealed his/her only concern was the facility was not allowing visitors, except by appointment. He/she stated, Many of us miss our family. Resident #15 further stated roommate missed his/her grandchildren who used to visit all the time. Resident #15 stated the roommated had not seen his/her family in over one (1) year due to COVID-19. Resident #15 stated visitors could only come in once a week. Stated he/she went out to dinner with his/her daughter last week. Both had been fully vaccinated. He/she was unaware of any changes to the facility visitation policy, and had not received any recent notification about a Visitation Policy update. Review of Resident #15's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Interview with Resident #16, on 06/15/2021 at 2:15 PM revealed he/she missed frequent visits from family. He/she stated it had been a long time since he/she had seen his/her grandchildren. Resident #16 stated when he/she thought about when he/she would see them again, it made him/her very sad. He/she was unaware of any changes to the facility visitation policy, and had not received any recent notification about a Visitation Policy update. Review of Resident #16's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Observation of Resident #2, on 06/16/2021 at 12:00 PM, revealed he was sitting in a wheelchair with his/her head downcast. When SSA Surveyor asked how he/she was doing, the resident replied that everything was ok, but further stated, he/she really missed his/her spouse. Per interview, Resident #2 stated his/her spouse visited, but would like him/her to come more often. He stated again, he/she missed his/her spouse and son. Resident #2 stated he/she did not know the reason his/her family could not visit often. Resident #2 stated his/her son brought his/her spouse to visit when he could. Review of Resident #2's medical record revealed he/she was admitted on [DATE] and had a Brief Interview for Mental Status score of three, indicating the resident had severe cognitive impairment. Interview with Resident #18, Resident Council President, on 06/16/2021 at 2:25 PM, revealed he/she has not presided over a Resident Council meeting in over one (1) year, due to COVID-19. He/she further stated that residents' visits with family were very limited. Resident #18 stated he/she did not get to see his/her daughter as much as he/she would like. Resident #18 stated he/she and other residents were lonely without visits. He/she was unaware of any changes to the facility visitation policy, and had not received any recent notification about a Visitation Policy update. Review of Resident #18's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Telephone interview with Resident #2's spouse, on 06/16/2021 at 1:19 PM, revealed the spouse was unaware of any changes to the facility visitation policy, and did not receive notification of the 06/01/2021 Visitation Policy update. Telephone interview with Resident #2's son, on 06/16/2021 at 3:55 PM, revealed the visitation restrictions had been very difficult on his family, and it has taken an emotional toll on his parents. He was unaware of any changes to the facility visitation policy, and did not receive notification of the 06/01/2021 Visitation Policy update. Telephone interview with Resident #18's daughter, on 06/17/2021 at 2:18 PM, revealed she was unaware of any update regarding visitation. When asked if she had received a text, or letter regarding of the 06/01/2021 Visitation Policy update, she replied, No, I don't think so. When asked if she received a text message or letter on March 12, 2021 regarding changes to visitation restrictions, she replied, No, I haven't. Interview with the Activities Director (AD), on 06/16/2021 at 1:41 PM, revealed the activities department had been the point of contact for many of the residents' families because she scheduled all visits. Continued interview with the AD on, 06/16/2021 at 5:18 PM, revealed the Activities Department was responsible for scheduling and managing visitations. According to the AD, she was not aware the facility had opened up additional locations to accommodate more visits. Furthermore, she stated she was not aware of any communication updating residents and families of a new visitation policy as of 06/01/2021. Interview with the Interim Director of Nursing (IDON), on 06/16/2021 at 4:29 PM, revealed that a 'new' visitation policy was in effect, but was unaware of the exact date was effective but stated it was implemented, A few days ago. She further indicated she did not have a copy of the policy, and stated, The only copy is on the Administrator's computer, and she was unable to access the policy now. She stated while she did not know the specific days and times visitations were allowed, she did know that the facility had added additional days and hours to the visitation schedule, and was allowing more locations for visits in lobby sitting room and courtyard. She stated the Activities Department was responsible for managing and scheduling all visitation. The IDON was unsure if residents had been apprised of the updated Visitation Policy, and said if they were updated it would have been at a Resident Council meetings. She believed communication regarding the Visitation Policy update was sent via text message to the Resident's responsible party, but could not say for certain. Continued interview revealed families could receive important policy changes by text message and mail. She further stated a copy of the Visitation Policy was kept in a binder in the front lobby for anyone to review but was unsure if it was the most current version. Did we ask about the outcome for residents that did not have access or ability to read/understand the binder??? or for residents b/c families did not receive the text message because they do not prefer/want that platform of communication or did not have visits because they were not aware they could have visits and tell their family to schedule a visit due to not receiving the update? Was the DON interviewed? Telephone interview with the Administrator, on 06/17/2021 at 2:30 PM, revealed the visitation policy given to SSA Surveyor on 06/17/2021 was effective June 1, 2021. She stated that not much was changed in the new update. Administrator stated she informed residents and families about policy changes and changes in facility operations frequently through text messages. She stated responsible parties must approve of text message alerts before the facility would send them visitation updates via text message. Continued interview revealed the last text communication sent to families that approved of text message alerts regarding resident visitation, or policy updates, was dated March 12, 2021. When questioned how families and residents have been informed regarding the June 1, 2021 policy update, stated a copy of the Visitation Policy was kept in a binder in the front lobby for all to review. She further stated that she personally informed those family members who visit frequently of the updated policy. Did we ask about the outcome for residents that did not have access or ability to read/understand the binder??? or for residents b/c families did not receive the text message because they do not prefer/want that platform of communication or did not have visits because they were not aware they could have visits and tell their family to schedule a visit due to not receiving the update?

Based on interview, record review, review of the facility's policies, and review of the Plan of Correction (POC) for the 06/17/2021 Abbreviated/Partial Extended Survey, and the Revisit Survey, with an exit date of 08/05/2021, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) Program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by the repeat deficiency from the Abbreviated/Partial Extended Survey, with an exit date of 06/17/2021, at CFR 483.80 Infection Control, F-880. The facility failed to implement procedures, as stated in the POC, to ensure staff was compliant with infection prevention and control (IPC) measures. During the survey, it was identified the facility failed to ensure staff followed the established procedures for disinfecting shared equipment to ensure full cleaning and disinfection per the user instructions in order to prevent the spread of potential infection to other residents. Furthermore, the facility failed to ensure staff followed the established procedures for hand hygiene and appropriate use of personal protective equipment (PPE). The facility's leadership was in-serviced on the QAPI plan and the objectives of the plan: to provide a means to identify and resolve present and potential negative outcomes related to IPC; to establish and implement plans to correct deficiencies; and to monitor the effects of these action plans, and compliance of staff. However, the facility failed to ensure plans and actions implemented for the deficiencies cited, on 06/17/2021, were carried out to correct the identified deficiencies by the Acceptable Plan of Correction, dated 07/16/2021, with an allegation of compliance date of 07/19/2021. The findings include: Review of the facility's policy titled, Quality Assurance Committee Policy, not dated, revealed the facility shall establish a QAPI Committee for the purpose of maintaining programs for quality assessment and assurance. The committee's responsibilities included identifying and addressing quality issues. Furthermore, the QAPI Committee developed and implemented corrective action plans to correct any identified quality deficiencies. Review of the policy revealed the committee would monitor those areas which negatively affected quality of care provided to its residents. Review of the facility's Plan of Correction (PoC), Criteria 4, with an allegation of compliance date of 07/19/2021, revealed the Director of Nursing (DON), the ADON (Assistant Director of Nursing) and Supervisors would utilize the QAPI audit tool to monitor ten (10) percent of the staff every week for four (4) weeks for compliance of infection control procedures. Monitoring included issues related to the proper procedure for handwashing and hand sanitization, and the cleaning and disinfection of shared medical equipment to prevent the spread of infection. Furthermore, nursing staff would receive random handwashing competency checkoffs for ten (10) percent of the staff weekly for four (4) weeks. Review of the QAPI Infection Control audit tool, dated 07/09/2021, 07/16/2021, 07/23/2021, and 07/30/2021 revealed they all audited ten (10) staff members, except the audit, on 07/16/2021, which audited seven (7) staff members. All audits revealed staff members were observed for proper procedure for handwashing/hand sanitization and the cleaning and disinfection of shared medical equipment. All audits showed one hundred (100) percent compliance. Interview with the Infection Preventionist (IP), on 08/04/2021 at 3:40 PM, revealed all facility staff received IPC training, which included proper hand hygiene techniques, appropriate use of PPE, and the correct way to clean and disinfect shared medical equipment. The IP stated leadership monitored staff for compliance. Per the interview, the IP stated nursing staff was educated to read the manufacturer's instructions if there was a question as to how to clean an item. She stated she expected that staff followed the facility's policy and the POC. The IP stated this was important for the health and safety of the residents. Continued interview with the IP, on 08/05/2021 at 2:35 PM, revealed the IP stated that spraying shared equipment with Lysol did not follow the POC. Per the interview, the IP stated staff should have been corrected and educated to follow POC guidelines for the cleaning of shared equipment. Interview with the ADON, on 08/04/2021 at 3:55 PM, revealed staff had completed the required education and training modules per the POC. She stated nursing leadership (DON, ADON, and IP) audited staff compliance per the POC and continued to observe all staff randomly to maintain compliance and as part of the facility's QAPI program. According to the ADON, the audit process had not identified deficient practice related to IPC practices. The ADON stated following IPC practices was important to prevent the spread of infection and disease. Interview with the DON, on 08/04/2021 at 4:30 PM, revealed staff completed the required education and training modules per the POC. She stated nursing leadership audited staff compliance per the POC and continued to observe all staff randomly to maintain compliance. The DON stated it was her expectation that staff followed the facility's policies and the POC for cleaning shared equipment and other IPC practices. Continued interview revealed the DON stated nursing leadership and the Administrator did random spot checks to monitor compliance, and the ADON was responsible for performing formal audits of staff compliance as part of the QAPI program. According to the DON, the audit process had not identified deficient practice related to IPC practices. Additionally, it was the DON's expectation that the staff followed proper Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. She stated she expected the IPC policies to be maintained and the POC followed to prevent the spread of infection and for the safety of staff and residents. Interview with the Administrator, on 08/05/2021 at 4:28 PM, revealed all but one (1) staff member, who was out on medical leave, had been in-serviced related to all deficiencies identified from the 06/17/2021 survey, by 07/18/2021. Per the interview, she had discussed her expectations of the POC process with staff. Additionally, she stated the ADON was responsible for performing the audits. Per the interview, the DON or Administrator was responsible for ensuring the overall execution of the POC and the implementation of staff compliance audits. At the QAPI Committee, the Administrator stated she presented the initial concerns related to findings from a survey, conducted by the State Survey Agency (SSA), with the exit date of 06/17/2021. She stated a POC was developed, which included monitoring staff compliance of IPC measures weekly for one (1) month, and once a month for two (2) months by auditing staff compliance for proper procedure for handwashing/hand sanitization and the cleaning and disinfection of shared medical equipment. She stated the QAPI Committee expected a compliance rate of at least ninety-five (95) percent. Continued interview with the Administrator, on 08/05/2021 at 4:28 PM, revealed the facility held monthly QAPI meetings, which included the Administrator, Medical Director, DON, ADON, Infection Preventionist (IP), Social Services, Human Resources, and the Medical Records Coordinator in attendance. She stated, during the QAPI meetings, on 07/07/2021 and 07/26/2021, the results of the audit tool, addressing the compliance of IPC practices, and the POC for F-880 (the infection control deficiency) were reviewed thoroughly. Per the interview, the QAPI Committee identified no concerns related to IPC practices, nor did the committee recognize any areas for improvement. Additional interview with the Administrator, on 08/05/2021 at 5:56 PM, revealed the Administrator expected that staff followed the POC and the facility's policies related to IPC practices. Furthermore, it was her expectation that the staff followed proper CDC guidelines for hand hygiene and the use of PPE. She stated she expected the IPC policies to be maintained and followed to ensure the highest health and safety of the residents. Continued interview with the Administrator, on 08/05/2021 at 5:56 PM, revealed the facility's leadership, through audits and QAPI Committee meetings, established to ensure staff was compliant with IPC practices per the facility's policies and CDC guidelines, did not identify the facility practices related to IPC that were deficient. Per the interview, these established processes did not identify that shared medical equipment was not cleaned and disinfected appropriately between residents' use and hand hygiene and appropriate use of PPE was not practiced per the POC.

Based on observation, interview, review of the facility's policies, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, and review of the manufacturer's guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. These failures affected six (6) of twenty-two (22) sampled residents, Resident #1, #2, #3, #7, #12, and #20. Observations revealed an undated oxygen tubing, lying on the floor; medical supplies stored on the unswept floor of the clean linen closet; shared medical equipment not disinfected between resident use; opened dirty linen bags being moved between rooms and dirty linen on the floor of the resident's room; improper hand hygiene; a dirty ice scoop holder and straps holding the ice chest; and no face masks or alcohol based hand rub (ABHR) available at the staff screening area for staff to use. Observation of SRNA #2, on 06/14/2021 at 3:40 PM, revealed she failed to perform hand hygiene before and after passing out ice and water to the residents in room [ROOM NUMBER], These resident's need #'s can we give them Numbers maybe look at the matrix Resident #2 and #3. Continued observation of SRNA #2, revealed she placed several fingers inside a drink cup to support it as she filled it with ice. The findings include: Review of the facility's policy titled, Emergency Procedure-Pandemic Coronavirus, revised 03/2020, revealed the facility would require staff to use Standard and/or Droplet precautions to control and prevent infection. Review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, revised 09/2012, revealed the purpose of the policy was to provide guidelines for general infection control while caring for residents. Standard Precautions would be used when caring for residents at all times regardless of their suspected or confirmed infection status. Additional review revealed if the use of common items were unavoidable, then the shared equipment would be cleaned and disinfected before use with another resident. Review of the facility's policy titled, Infection Control Policy, no date, revealed the intended purpose of the policy was to facilitate and maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infections. Further review revealed a policy objective was to provide guidelines for the safe cleaning of shared medical equipment. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revision date 07/2014, revealed reusable non-critical items, i.e., blood pressure cuffs and stethoscopes, were cleaned and disinfected between residents. Additional review revealed resident care equipment would be cleaned and disinfected according to the manufacturer's instructions. Review of the facility's policy titled, Handwashing/Hand Hygiene, revision date 08/2014, revealed handwashing was the primary means to prevent the spread of infection. All personnel would follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Further review revealed hand hygiene products and supplies, i.e., towels and alcohol based hand rub would be readily accessible and convenient for staff to use to encourage compliance with hand hygiene. Additional review revealed staff was to use alcohol-based hand rub (ABHR) before and after resident contact, after contact with objects in the immediate vicinity of the resident, and after removing gloves. Review of the facility's policy titled, Departmental (Environmental Services)-Laundry and Linens, revised 03/2020, revealed staff should consider all soiled linen to be potentially infectious and handle using Standard Precautions. Further review revealed staff should wash hands after handling soiled linen. Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, last reviewed 01/08/2021, revealed hand hygiene reduced the spread of potentially deadly germs to residents. ABHR and washing hands with soap and water were the two (2) methods for hand hygiene. Continued review revealed there were multiple opportunities for hand hygiene to occur during a single care episode. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient; after touching a patient or the patient's immediate environment; when hands were visibly soiled; after contact with blood, body fluids or contaminated surfaces; and immediately after glove removal. Review of Super Sani-Cloth Germicidal Wipe Cleaning and Disinfecting Instructions, no date, revealed treated surfaces must remain wet for a full two (2) minutes. Additional review revealed heavily soiled surfaces required a two-step process. According to Super Sani-Cloth instructions, two (2) wipes were needed; one to clean the soiled surface of the item, and a second wipe to disinfect the item. 1. Observation, during the initial tour of the facility, on 06/14/2021 at approximately 2:50 PM, revealed dirty linen on the floor of room [ROOM NUMBER]. Additional observation revealed Resident #1's oxygen tubing and cannula was not dated and was lying on the floor. Interview with State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #1, on 06/15/2021 at approximately 10:48 AM, revealed, per policy, dirty linen and trash were bagged in the resident's room and then disposed of in the dirty utility room. Per interview, staff was trained on infection control and prevention (ICP) practices upon hire and during in-service training. She stated following ICP practices was important to prevent the spread of infection. Interview with SRNA #4, on 06/15/2021 at 4:15 PM, revealed, per policy, dirty linen and trash were bagged in the resident's room and then disposed of in the dirty utility room. Per interview, staff was trained on ICP practices upon hire and during in-service training. He stated training related to ICP practices was important to prevent the spread of infection. Interview with Licensed Practical Nurse (LPN) #1, on 06/15/2021 at 3:59 PM, revealed soiled laundry was bagged in a clear plastic trash bag and immediately taken to the soiled linen room. She stated the soiled linen room contained dirty linen and dirty equipment, and following ICP practices was important to prevent the spread of infection and for the safety of the residents. 2. Observation of the clean linen closet, on 06/15/2021 at 10:40 AM, revealed medical supplies, i.e., mouth swabs and oxygen tubing, was stored on the floor. In addition, the floor of the linen closet was unswept and contained trash consisting of dirt, dust, and multiple opened package debris. Interview with LPN #3, on 06/15/2021 at 10:41 AM, revealed medical supplies were to be stored on a shelf and not on the floor. LPN #3 removed contaminated supplies from the floor. Additional interview revealed she received ICP training upon hire and then continually throughout the year. She stated storing medical supplies properly prevented the spread of infection. 3. Observation and interview of Registered Nurse (RN) #1, on 06/15/2021 at 10:56 AM, revealed she failed to disinfect a blood pressure wrist cuff when it was used between residents. Further interview revealed it was facility procedure to clean and disinfect shared medical equipment, including portable blood pressure cuffs, with one (1) Sani-Cloth disinfectant wipe, and allow the equipment to dry for sixty (60) seconds. Interview with LPN #1, on 06/15/2021 at 3:59 PM, revealed shared medical equipment was cleaned with one (1) Sani-Cloth disinfectant wipe, and the equipment was allowed to dry for sixty (60) seconds between resident use. Review of Sani-Cloth user instructions revealed users should allow treated items to stay wet for two (2) minutes and air dry for full disinfection. 4. Observation, on 06/15/2021 at 2:15 PM, revealed SRNA #3 going from room [ROOM NUMBER] to room [ROOM NUMBER] with two (2) opened dirty linen bags, and she failed to doff gloves or hand sanitize appropriately between rooms. The residents in these rooms were Residents #7, #12, and #20. Interview with SRNA #3, on 06/15/2021 at 2:15 PM, revealed SRNA #3 usually tied bags before exiting resident rooms and taking the dirty linen and trash to the dirty utility room. She reported she tried to doff gloves inside the room and use the resident's sink to wash hands prior to exiting the room. What do we mean Tried and were hands actually Washed??? SRNA #3 stated it was important to doff gloves, use ABHR, and use a new bag in each resident's room to prevent the spread of germs. In addition, SRNA #3 stated hand hygiene was required before and after resident care and prior to resident contact. Per interview, SRNA #3 stated soiled gloves and personal protective equipment (PPE) should be disposed of before leaving a resident's room. Further, SRNA #3 reported she received ICP training upon hire and then continually throughout the year. Continued interview with SRNA/KMA #1, on 06/15/2021 at approximately 10:48 AM, revealed, per policy, soiled gloves and personal protective equipment (PPE) were disposed of before leaving a resident's room. SRNA/KMA #1 stated, per policy, hand hygiene was required before and after patient care, and after touching contaminated surfaces. Continued interview with SRNA #4, on 06/15/2021 at 4:15 PM, revealed, per policy, all PPE should be doffed prior to exiting a resident's room and disposed of in a trash receptacle. SRNA #4 stated hand hygiene was important for patient safety and to prevent the spread of infection. 5. Observation of SRNA #2, on 06/14/2021 at 3:40 PM, revealed she failed to perform hand hygiene before and after passing out ice and water to the residents in room [ROOM NUMBER], These residents need #'s Resident #2 and #3. Continued observation of SRNA #2, revealed she placed several fingers inside a drink cup to support it as she filled it with ice. She proceeded to hold the resident's cup over the ice in the chest as she overfilled the cup causing ice that had touched the resident's cup and the SRNA's fingers to fall back into the ice chest. SRNA #2 placed the lid and the straw on the cup and served it to Resident #2. When SRNA #2 came out of room [ROOM NUMBER], her hands were visibly wet and she was shaking the water off. Further observation revealed SRNA #2 replaced the scoop and closed the lid of the ice chest and locked it with a padlock. Observation of the ice chest and ice scoop holder, revealed a dark black dirt-like substance on the inside perimeter of the scoop holder. In addition, the outside white straps holding the ice chest had turned dark brown and had the appearance of a black fuzzy growth. Interview with SRNA #2, on 06/14/2021 at 3:46 PM, revealed she did not realize she placed her fingers inside the cup. She further stated that she used ABHR prior to serving refreshments. She stated she was not sure if she needed to wear gloves when passing ice. Per interview, SRNA #3 stated there were no paper towels in the bathroom to dry her hands. 6. Observation of the staff entrance self-screening table, on 06/14/2021 at 3:00 PM, revealed a thermometer and a COVID-19 questionnaire. There was no ABHR available for staff to use, even though the policy stated ABHR would be readily accessible and convenient for staff to use to encourage compliance with hand hygiene. Do we have interviews about the above observation??? Interview with the Licensed Practical Nurse/Infection Preventionist (LPN/IP), on 06/14/2021 at approximately 2:10 PM, revealed it was her expectation that all soiled linen and trash were to be bagged and tied prior to exiting a resident's room and placed immediately in the dirty utility room. Further interview revealed it was her expectation that staff followed all facility policies regarding ICP practices. Additionally, she stated ICP education was provided upon hire, as part of employee annual training, and in-service training was provided throughout the year; changes in infection control policies or procedures were communicated by word of mouth and through demonstration and teach back. Continued interview with the LPN/IP, on 06/14/2021 at approximately 2:10 PM, revealed she and the nursing supervisors audited staff for compliance related to ICP practices; however, she stated she had never documented her compliance audits. The LPN/IP stated that oxygen tubing was to be dated when changed because it was important to prevent the spread of infection. In addition, she stated she expected shared medical equipment to be cleaned and disinfected between residents according to facility policy and manufacturer's guidelines to prevent the spread of infection. Furthermore, she stated she expected staff to use proper hand hygiene techniques routinely and according to facility policy and current State and Local Health Department (LHD) ICP guidelines. Interview with the Environmental Services Director (ESD), on 06/16/2021 at 4:49 PM, revealed housekeeping staff followed infection control policies in response to COVID-19 recommendations. He stated it was his expectation that linen be bagged in the resident's room and taken immediately to the dirty utility room. Furthermore, he stated staff should practice appropriate hand hygiene to prevent infection. Interview with the Interim Director of Nursing (IDON), on 06/15/2021 at 2:50 PM, revealed she expected soiled linen to be bagged and immediately taken to the dirty utility room for proper disposal. The IDON stated dirty linen should not be thrown on the floor, and oxygen tubing and nasal cannulas were changed once a week and should be dated when changed. Per interview, the IDON stated it was important to date oxygen tubing to prevent respiratory infections. In addition, she stated all beverage carts should be kept clean and scoops covered for infection control and clean supplies should be stored on shelves and off the floor to prevent contamination. She stated the facility followed State and Federal ICP guidelines. Per the IDON, she expected all staff to follow ICP guidelines to decrease the chance of the spread of infection and for the safety of residents and staff. Furthermore, she stated she expected staff to use proper hand hygiene techniques routinely, before and after each resident's care, before and after each medication pass, at meal service, and when visibly soiled. Post-Survey interview with the Administrator, on 06/23/2021 at 4:05 PM, revealed it was her expectation that facility staff follow ICP guidelines at all times. She stated it was important to uphold ICP practices for the safety of the residents.

Based on interview, record review, and review of the Manufacturer's Recommendations for Use of the transfer pole, it was determined the facility failed to take appropriate precautions to ensure a safe environment to prevent avoidable accidents for five (5) of twenty (20) sampled Residents (#32, #38, #54, #70 #72). Residents #32, #38, #54, #70 #72 had a transfer pole device installed in their rooms. The facility failed to ensure the transfer devices were installed per the Manufacturer's Recommendations for Use (MRU) to prevent avoidable accidents and ensure the residents' safety. The findings include: Review of the Stander Inc. Transfer Pole, Stander Be Independent Security Pole Description pamphlet, undated, revealed the Stander Security Pole and Curve Grab Bar offered a secure and safe support structure to assist mobility patients with transferring from a sitting position to a standing position. Review of the MRU for the Stander Be Independent Security Pole, undated, Section titled, Warning Entrapment and Falling Hazard, revealed small gaps between the pole/swivel handle and other stationary objects could trap and kill. Further, it stated people with [MEDICAL CONDITION], Dementia, use of sedation, confusion, or frailty were at an increased risk of entrapment and falls. Further review revealed failure to comply with installation instructions, which were important, could put the user(s) at risk of entrapment or falling. Continued review revealed the MRU stated if installing the pole product next to a bed, couch, toilet, or any other object, it was recommended to not install the product closer that the user(s) ability to safely walk around the pole or there could be a possibility of becoming entrapped between the pole and the side of any object adjacent to the pole. In addition, it stated the user must be able to safely walk around the pole in every swivel handle position, and it was the user(s)' responsibility to ensure there was no possible way to become entrapped between the pole and/or pivoting handle and the side of any object adjacent to the pole. Per the MRU, more specifically, this included the bed, couch, toilet, or any other object. 1. Review of Resident #54's medical record revealed the facility admitted the resident on 12/14/2017, with [DIAGNOSES REDACTED]. Review of Resident #54's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #54 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was not cognitively intact. Continued review of Section G, Functional Status, revealed the facility assessed the resident to require limited assistance and one (1) person physical assistance with bed mobility, and limited assistance and one (1) person physical assistance with transfers. Review of Resident #54's Comprehensive Care Plan (CCP) revealed a focus of the resident was at risk for falls and/or injury secondary to a history of falls, and dependence on staff for bed mobility and transfers, and resident would sit on floor when tired of ambulating, dated 08/03/2020. The goal stated Resident #54 would remain free of injury from falls through the next review. Further review revealed the approaches were to encourage the resident to be as independent as safely possible; to encourage the resident to wear nonskid footwear; to remind the resident to use the call light, ensuring its accessibility at all times; to have a transfer pole at the bedside; to position the bed against the left wall per family request; and to have therapy evaluations as needed and ordered. Review of Resident #54's Nurse Aide Care Plan revealed, under Comments, the resident had a transfer pole. Review of Resident #54's Physical Therapy - Therapist Progress and Updated Plan of Care notes, dated 01/17/2020, revealed justifications for continued skilled services included strength impairments, safety awareness deficits, lower extremity strength, decreased safety awareness, and decreased dynamic balance. In addition the notes stated bed mobility and transfer training were initiated, including the use of a transfer pole. Observation of Resident #54's room, on 09/22/2020 at 10:45 AM, revealed the resident had a transfer pole placed near his/her bed. Observation of Resident #54's room, on 09/23/2020 at 2:35 PM, revealed the transfer pole was measured to be three and a half (3.5) inches away from the resident's bed. Interview with Licensed Practical Nurse (LPN) #1, on 09/23/2020 at 3:23 PM, revealed she was caring for Resident #54 that day. She stated Resident #54 utilized the transfer pole to stabilize himself/herself during transfers. Interview with State Registered Nursing Assistant (SRNA) #1, on 09/23/2020 at 3:45 PM, revealed she was caring for Resident #54 that day. She stated Resident #54 did not ambulate great distances and utilized the transfer pole to stabilize himself/herself during transfers. 2. Review of Resident #70's medical record revealed the facility admitted the resident, on 08/12/2016, with [DIAGNOSES REDACTED]. Review of Resident #70's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #70 to have a BIMS score of three (3) out of fifteen (15), indicating the resident was not cognitively intact. Continued review of Section G, Functional Status, revealed the facility assessed the resident to require limited assistance and one (1) person physical assistance with bed mobility and limited assistance and two (2) person physical assistance with transfers. Review of Resident #70's CCP revealed a focus of the resident was at risk for injury secondary to Generalized Weakness, History of Falls, Diabetes Mellitus, Gait Disorder, Impaired Cognition, and Dementia. Continued review revealed Resident #70 was dependent on staff for assistance, but non-compliant in asking for assistance, dated 08/21/2020. The goal stated the resident would remain free of injury from falls through the next review. Further review revealed the approaches stated have transfer pole to the right side of the bed because the left side of the bed was against the wall; have call light within reach; and answer call light in a timely manner. Review of Resident #70's Nurse Aide Care Plan, under Comments, revealed the resident had a transfer pole. Review of Resident #'70's Physical Therapy - Recertification and Updated Plan of Care notes, dated 10/31/2019, revealed clinical impressions and reasoning for skilled services included to minimize falls, to increase lower extremity range of motion, to increase functional activity tolerance, to improve dynamic balance, and to promote safety to enhance the resident's quality of life. Further review revealed, in the section Impact on Burden of Care/Daily Life, stated the resident required the transfer pole to transfer out of bed and the mechanical lift for toileting tasks. Further review revealed interventions applied included the transfer pole, with resident and caregiver training. Observation of Resident #70's room, on 09/22/2020 at 11:25 AM, revealed the resident had a transfer pole placed near his/her bed. Observation of Resident #70's room, on 09/23/2020 at 3:25 PM, revealed the transfer pole was measured to be four (4) inches away from the resident's bed. Continued observation of Resident #70's room revealed there was not enough space between the pole and the resident's bed for the resident to safely walk around the transfer pole without the possibility of becoming entrapped. Interview with LPN #1, on 09/23/2020 at 3:23 PM, revealed she was caring for Resident #70 on that date and stated it was necessary for the resident to hold the transfer pole during transfers due to lack of strength. Additional interview with LPN #1, on 09/23/2020 at 3:30 PM, revealed she was trained during orientation on the transfer pole by the therapy department. Continued interview revealed there was no clear reason provided to her concerning any safety measures with the use of the transfer pole. Per interview, she was not sure of the safety concerns with the transfer pole; however, from many years of clinical experience, a resident's head could become trapped by the transfer pole. Interview with SRNA #1, on 09/23/2020 at 3:45 PM, revealed she was caring for Resident #70 on that date and stated the resident did not ambulate and used the transfer pole during transfers. SRNA #1 revealed training for transferring residents was given during orientation and, at other times, by therapy. She stated she was not instructed on any safety measures with use of the transfer pole. Per interview, there was a knob located on the pole that could be used to move the handles to the correct position for the resident. 3. Review of Resident #32's medical record revealed the facility admitted the resident, on 01/14/2019, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15) indicating the resident was cognitively impaired. Continued review of the Quarterly MDS, section G, revealed Resident #32 required one (1) person assist for transfers. Review of Physician Orders, dated 03/18/2020, revealed Resident #32 was to perform all transfers with assist of one (1). Further review revealed a Physician Order, dated 04/21/2020, revealed Resident #32 was to transfer from the wheel chair to the bed with assist of transfer pole and one (1) person assist. Review of the CCP, dated 07/20/2020, revealed a focus on falls secondary to weakness, cognition, and history of falls. The goal was Resident #32 would remain free of injury from falls through the next review with a target date of 10/20/2020. Interventions, not dated, revealed to use the pole with assist as ordered; on 09/15/2020, non-slip grips to be used on the transfer pole for transfers. Continued review of the CCP, dated 07/20/2020, revealed Resident #32 required assistance with activities of daily living (ADL) due to Weakness, Fracture, Dementia, Pain and History of Falls. The goal was Resident #32 would continue to participate with ADL's as able through the next review with a target date of 10/20/2020. An intervention, not dated, was the resident would use the transfer pole. Review of the Daily Care Plan Record, a nurse aide care plan, not dated, revealed Resident #32 required an assist of one (1) for transfer with the pole. Review of the Bed Safety Assessment, dated 04/21/2020, revealed Resident #32 had limited bed mobility, difficulty moving to a sitting position on the side of the bed, and poor trunk control. Further review of the assessment revealed an alteration in safety awareness. Review of the Fall Incident Report, on 09/15/2020 at 5:30 PM, revealed Resident #32 had fallen from the transfer pole while trying to self transfer from the wheelchair to the bed. The resident stated his/her hand slipped while trying to self transfer. Resident #32 was assessed and had no injuries, vital signs taken, and notifications made to the Physician and family. Observation, on 09/22/2020 at 12:00 PM, revealed a transfer pole located to the left side of Resident #32's bed. Observation, on 09/24/2020 at 2:45 PM, of Resident #32's room revealed a pole beside the bed which measured three (3) inches between the bed and the pole. The transfer pole had non-slip grips wrapped around the elbow of the pole. Interview with State Registered Nurse Aide (SRNA) #1, on 09/24/2020 at 2:45 PM, revealed Resident #32 had a transfer pole near the bed. She stated it took one (1) staff to assist Resident #32 with transfers. SRNA #1 stated therapy evaluated the resident's need and use of the transfer pole. Interview with SRNA #2, on 09/24/2020 at 2:50 PM, revealed therapy trained the staff and maintenance installed the poles. SRNA #2 stated she had not worked with Resident #32. Interview with the Occupational Therapist (OT), on 09/24/2020 at 3:15 PM, revealed Resident #32 was a one (1) person assist. The OT stated therapy would train staff on transfers of residents using the pole. 4. Review of Resident #38's medical record revealed the facility admitted the resident, on 11/11/2019, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #38 as having a BIMS of six (6) out of fifteen (15) indicating the resident had cognitive impairment. Continued review of the MDS, section G, revealed Resident #38 required a two (2) person assist with transfers. Review of Resident #38's Physician Orders, dated 01/27/2020, revealed he/she was to use side rails and the transfer pole to right side of the bed per therapy. Review of the CCP, dated 07/24/2020, revealed a focus of the resident was at risk for injury related to falls secondary to History of Falls, Weakness, Debility, [MEDICAL CONDITION], and Impaired Cognition. The goal for Resident #38 was to remain free of injury from falls through the next review with a target date of 02/21/2020. An intervention, dated 09/22/2020, was therapy to re-evaluate safety of the transfer pole. Further review of the CCP, dated 07/24/2020, revealed another focus of Resident #38 required assistance with ADL's related to Weakness, Debility, Unsteady Gait, Decreased Mobility, [MEDICAL CONDITION], and Impaired Cognition. The goal was Resident #38 would remain comfortable through the end of life with a target date of 10/20/2020. Interventions were for 1/2 side rails x 2 for assistance with turning and repositioning. Review of Resident #38's Daily Care Plan Record, not dated, revealed transfers required an assist of one (1) with a stand-up life and a transfer pole at the bedside. Review of Resident #38's Bed Safety Assessment, dated 01/27/2020, revealed bed rails were assessed for safety, and the gap was assessed for risk of entrapment; the measurement should not be more than 2.5 inches from the bed to the rail. Continued review of the assessment revealed Resident #38 had limited bed mobility, poor trunk control, poor safety awareness, and difficulty moving to a sitting position on the side of the bed. Therefore, requirements for the resident were side rails for positioning, rails raised while in bed, and increased safety precautions. Review of Physical Therapy notes for Resident #38, dated 01/28/2020 through 03/09/2020, revealed the reasons for skilled services were to minimize falls, promote safety awareness, and increase lower extremity (LE) range of motion (ROM). Review of Occupational Therapy notes for Resident #38, dated 01/27/2020 to 03/22/2020, in clinical impressions, revealed Resident #38 demonstrated deficits with bilateral upper extremities (BUE) strength, trunk strength, and balance which showed an increased need for assistance with ADL's. Continued review of the Occupational Therapy Discharge Summary, dated 03/30/2020, revealed a recommendation for grab bars. Observation, on 09/22/2020 at 12:05 PM, of Resident #38's room revealed a transfer pole located to the right side of the bed. Observation, on 09/24/2020 at 3:02 PM, of Resident #38's bed showed the transfer pole was measured at 9.0 inches from the bed rail to the pole and 10.5 inches from the bed to the pole. Interview with SRNA #1, on 09/24/2020 at 2:45 PM, revealed Resident #38 had a transfer pole near the bed. She stated it took two (2) staff to assist Resident #38 with transfers using the transfer pole. Interview with SRNA #2, on 09/24/2020 at 2:50 PM, revealed he was trained by therapy on how to use the transfer poles with each Resident. SRNA stated Resident #38 required a two (2) person assist using the pole. Interview with the Occupational Therapist (OT) #1, on 09/24/20 at 3:16 PM, revealed transfers were practiced with Resident #38 with one (1) assist for cueing using the transfer pole. The OT stated pole safety awareness was encouraged. Interview with Physical Therapy (PT) #1, on 09/24/20 at 3:44 PM, stated Resident #38 was an assist of one (1) when using the transfer pole. 5. Review of Resident #72's medical record revealed the facility admitted the resident, on 08/21/2017, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/07/2020, revealed the facility assessed the resident as having a BIMS of four (4) out of fifteen (15) for cognitively impaired. Continued review of the MDS, section G, revealed Resident #72 required a one (1) person assist for transfers. Review of Resident #72's Physician Orders, dated 10/22/2019, revealed the resident was to have a transfer pole at the bedside to assist with transfers. Review of Resident #72's CCP, dated 08/08/2020, revealed a focus of the resident was at risk for injury related to falls secondary to Weakness. The goal was for the resident to remain free of injury from falls through the next review with a target date of 11/08/2020. The intervention was for a transfer pole at the bedside. Review of the Daily Care Plan Record, not dated, revealed Resident #72 required transfer assistance as needed (PRN) while using the transfer pole. Review of Resident #72's Bed Safety Assessment, dated 10/22/2019, revealed bed rails were assessed for safety, and the gap was assessed for risk of entrapment; the measurement should not be more than 2.5 inches from the bed to the rail. Continued review of the assessment revealed Resident #72 had limited bed mobility, poor trunk control, poor safety awareness, and difficulty moving to a sitting position on the side of the bed. Therefore, requirements for the resident were side rails for positioning, rails raised while in bed, and increased safety precautions. Review of Resident #72's Physical Therapy Discharge Summary, for dates of service 10/22/2019 to 12/20/2019, revealed he/she had a medical history of [REDACTED].#72 transferred from chair/bed-to-chair independently. Continued review of the Physical Therapy Evaluation and Plan of Treatment, dated 10/22/2019 to 12/20/2019, revealed the reason for Resident #72's referral was for a new onset of reduced dynamic balance with increased need for assistance from others, fall risk, decrease in strength, and decrease in functional mobility. Observation, on 09/22/2020 at 12:10 PM, of Resident #72's room revealed a transfer pole located to the right side of Resident #72's bed. Observation, on 09/24/2020 at 2:33 PM, of Resident #72's bed revealed the transfer pole measured six (6) inches from the bed to the pole. Interview with SRNA #1, on 09/24/2020 at 2:45 PM, revealed Resident #72 had a transfer pole near the bed, and therapy was working currently with the resident on transfers. Interview with SRNA #2, on 09/24/2020 at 2:50 PM, revealed residents were trained by therapy on how to use the transfer pole; however, Resident #72 had not been cleared for use of the transfer pole yet. Interview with the OT #1, on 09/24/2020 at 3:10 PM, revealed Resident #72 was not cleared for use of the transfer pole. The OT stated they were working in Resident #72's room with him/her on the use of the transfer pole. In addition, staff were not transferring with the transfer pole yet because they still needed to be observed using the transfer pole with Resident #72. Interview with the PT #1, on 09/24/20 at 2:43 PM, revealed Resident #72 needed assistance with transfers by using the Hoyer Lift while the therapists continued to work with Resident #72 in his/her room with the transfer pole. Additional interview with PT #1, on 09/24/2020 at 3:00 PM, revealed Physical Therapy (PT) would recommend transfer poles for residents based on need and benefit analysis. The PT stated staff were trained on proper use of transfer poles as were residents who were cognitively able to grasp such knowledge. The PT stated residents were not assessed in accordance to the MRU in terms of being able to ambulate around the pole when it was against an adjacent object. Interview with the Maintenance Director, on 09/24/2020 at 3:10 PM, revealed he was responsible for the installment of transfer poles in resident rooms. Continued interview revealed, before installment occurred, an order was received from the Director of Nursing (DON) to place the pole. Further, he stated a weekly check was required for the poles, but he tried to do it daily. He stated he received installment instructions and orders from a third party vendor. Per interview, the Director stated he had never seen the MRU's for the transfer pole, nor did it come in the box when the pole was received. Interview with the Therapy Manager, on 09/24/2020 at 3:45 PM, revealed the department assessed all residents in therapy for their transfer needs and all potential modalities based on their needs. He stated when assessing a resident with a possible need for a transfer pole, the resident was assessed for his/her current abilities and how the transfer pole could benefit the resident. In addition, he stated PT would work with Occupational Therapy (OT) to find the best placement of the transfer pole for the resident; then, maintenance placed/installed the transfer pole. Per interview, once the pole was installed, PT would work with the resident to prompt the resident and ensure the demonstration and competencies of both staff and residents were acceptable. Continued interview revealed in-services were provided to SRNA's and nurses to ensure they were competent in using the transfer pole. He stated OT's were trained in cognition to help ???residents utilize the transfer pole that were not cognitively aware. He stated residents did not use transfer poles without the assistance of staff. Per interview, he stated he was unaware of the MRU that stated the transfer pole needed to be installed at a distance from the bed to permit the resident to be able to walk all the way around the pole due to the risk of entrapment. Interview with the DON, on 09/24/2020 4:15 PM, revealed she expected transfer poles to be used for residents for any changes or decline in condition and report to her or therapy to reassess the need for the transfer pole. In addition, she stated she, too, was in the residents' rooms multiple times and saw the transfer poles. Further, the DON stated if a resident was non-ambulatory there was not an issue of becoming entrapped, as residents required staff to use the pole. She stated she was unaware of the MRU related to the placement of the transfer pole and its proximity to an object such as the bed or the chair. Continued interview with the DON, on 09/24/2020 at 5:24 PM, revealed transfer poles were used as a safety device. She stated the residents were assessed upon admission for risk of entrapment, and there was a complete reassessment of the transfer poles quarterly. Interview with the Administrator, on 09/24/2020 at 4:35 PM and again at 6:00 PM, revealed she expected residents to remain free from accidents and hazards. She stated she was aware residents were using transfer poles in their rooms to enable movement. She stated maintenance installed the transfer pole per the instructions that came with the pole. The Administrator stated she was unaware of the MRU's warning of the entrapment and falling hazards and the recommendation for the device to be installed to allow the resident to safely walk around the pole; and if this was not done, the resident could become entrapped between the pole and the side of any object adjacent to the pole causing severe injury or death. She stated therapy would evaluate the resident and recommend the placement of the transfer pole, and maintenance would place the pole per therapy's recommendation for pole placement. She stated the transfer pole was to be used as an assistive device to help the resident and enable them to hold their position in bed. She stated the facility did not perform a risk versus benefit analysis for transfer poles because the poles were viewed as an enabling device rather than a restrictive device. The Administrator stated there was a risk using any assistive device, and the facility did not perform a risk versus benefit analysis for wheelchairs or walkers. In addition, she revealed the facility did not use side rails on the residents' beds for fear of entrapment. Per interview, she stated residents that had transfer poles currently present in their rooms were not able to get up, use the transfer poles on their own, and required staff assistance to use the pole. She further stated, the MRU of the transfer pole would take away from the benefits and independence of some residents. The Administrator stated residents felt better and were able to move about easier when the transfer pole was used.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food under sanitary conditions. Observations, on 09/22/2020, of the tea and water cart revealed it was not cleaned between breakfast and lunch service, and the wall/baseboard in the hall in front of the steam table revealed dried food stains. Continued observations revealed the food thermometer was not properly sanitized between food items. The findings include: Review of the facility's policy titled, Food Holding Temperatures on Food Service Line, not dated, revealed the thermometer would be sanitized with alcohol swabs between taking each food's temperature. Review of the facility's policy titled, Sanitation, not dated, revealed the facility would maintain equipment, work surfaces, walls, and floors in sanitary condition through daily, ongoing procedures. Further review revealed formal sanitation inspections in the dietary department occurred on a frequent basis, and informal sanitation inspections occurred on a daily basis. Observation, on 09/22/2020 at 11:17 AM, revealed Cook #3, during preparation prior to the lunch meal service laid a cleaning cloth on the ledge in front of the steam table and used an alcohol wipe to clean the stem off the thermometer between food items. However, he did not always take the alcohol wipe out of the package, but pierced the package, and he would alternate wiping between a new alcohol wipe and the cleaning cloth; the cleaning cloth was not refreshed or kept in the sanitation bucket. Observations, on 09/22/2020 at 11:45 AM to 12:00 PM, of the lunch tray line service revealed the beverage cart with opened, empty juice cartons on a cart shelf and dry loose cereal sitting on the tray holding beverages for tea and water service. Continued observations of the beverage cart revealed a used soiled bowl sitting on the cart shelf. Further observations, during the lunch tray line service, revealed the walls and baseboards in front of the tray line had the appearance of dried food particles splashed across the wall and dried on the baseboards. Cook #3 could not be reached and was not available for interview. Interview with Cook #1, on 09/23/2020 at 2:11 PM, revealed to sanitize the food thermometer, the sanitizer wipe must be taken out of the packet and wiped between use on each food item to prevent cross-contamination between food items. Interview with Dietary Aide #3, on 09/23/2020 at 2:18 PM, revealed the inside of the walls near the tray line and the beverage cart were cleaned every night to prevent an accumulation of germs and bacteria. Interview with Cook #2, on 09/23/2020 at 2:23 PM, revealed the thermometer was wiped with an alcohol pad that had been removed from the packet between food items to prevent cross-contamination of food allergens, germs, or bacteria from being transmitted from food to food. Interview with Dietary Aide #1, on 09/24/2020 at 11:14 AM, revealed alcohol wipes must be used to clean the thermometer stem between each food item to prevent cross-contamination of allergens between food products. The Dietary Aide stated she tried to clean the beverage cart between meals; however, there was very little time to do this. She stated it was important to clean the beverage cart between meals to make the cart more sanitary and to wipe down walls after supper to prevent cross-contamination and the growth of bacteria and germs. Interview with Dietary Aide #4, on 09/24/2020 at 11:30 AM, revealed the beverage cart was cleaned after lunch, but there was not enough time to clean the cart between breakfast and lunch. She stated it was important to clean the beverage cart and to wipe the walls after lunch to prevent cross-contamination and germs/bacteria from spreading. Interview with the Registered Dietitian, on 09/23/2020 at 2:33 PM, revealed the dish cloth was kept in the sanitizer bucket at all times unless it was in use to prevent cross-contamination. She stated the food thermometer stem was cleaned with an alcohol wipe between each food item to prevent cross-contamination of allergens, and it was important to clean the walls daily between meals and at the end of the night to prevent attracting insects. The Dietician stated the beverage cart was sprayed, cleaned out, and deep cleaned at night to prevent cross-contamination and the attraction of insects. Interview with the Administrator, on 09/24/2020 at 5:45 PM, revealed Cook #3 told the facility he used a paper towel to wipe off the food thermometer. He stated staff did not have time to clean the beverage cart between meals, and deep cleaning occurred at night. The Administrator stated walls in the kitchen and in front of the steam table were cleaned daily.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections to properly prevent and/or contain COVID-19. Observation of medication administration, on 09/23/2020 at 8:30 AM, revealed Licensed Practical Nurse (LPN) #1 failed to wash or re-sanitize hands between Resident #51's medication administration and Resident #39's medication administration. Further observation revealed that Licensed Practical Nurse #1 dropped a green medication capsule on the top of the medication cart, a contaminated surface, picked it up with bare hands, and placed the capsule in the medication cup to administer to Resident #39. The findings include: Review of the facility's policy, Administering Medications Policy, revised December 2012, revealed medications would be administered in a safe, timely manner and as prescribed. Further review revealed staff would follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Handwashing Policy, dated 09/24/2014, revealed handwashing with soap and water was the best approach to hand hygiene; however, alcohol-based hand rub could be used in certain circumstances, unless hands were visibly soiled. Per policy, examples included contact with a resident's intact skin, taking blood pressure or pulse, performing a non-invasive physical assessment, lifting the resident in bed, and passing medications. Review of the facility's document Handwashing Performance Evaluation Checklist, dated 09/15/2020, revealed LPN #1 satisfactorily completed the education and competencies on handwashing. Observation of medication preparation and administration, on 09/23/2020 at 8:30 AM, revealed LPN #1, at the East Hallway Medication Cart, was preparing medications for Resident #51, who was sitting in the lobby. Further observation revealed LPN #1 reached for a pair of gloves, and one (1) glove dropped on the floor; LPN #1 discarded the dropped glove, retrieved another glove, put both gloves in her pocket, and went to Resident #51 to administer his/her medications. Per observation, LPN #1 did not wash or re-sanitize her hands before going to Resident #51 and administering his/her oral medications. Per observation, LPN #1 then donned a pair of gloves, administered two (2) sprays of [MEDICATION NAME] Nasal Spray into each nostril of Resident #51, and removed and discarded her gloves; but, she did not wash or sanitize her hands after removing the gloves. Continued observation revealed LPN #1 prepared Resident #39's medications without washing or sanitizing his/her hands. In addition, LPN #1 dropped a green medication capsule on the top surface of the medication cart, a contaminated surface, picked it up with her bare hands, broke open the capsule, and then emptied the contents into the medication cup. Further observation revealed LPN #1 went to Resident #39's room and administered the medication that had dropped onto the medication cart. Interview with LPN #1, on 09/24/2020 at 10:35 AM, revealed she had been employed at the facility for approximately one (1) year. She stated she should have washed or sanitized her hands after picking up the glove from the floor and before administering medications to Resident #39. Further interview revealed she should have performed hand hygiene between Resident #51's medication administration and Resident #39's medication administration. In addition, LPN #1 stated she probably should have discarded the capsule dropped on the surface of the medication cart and retrieved another one. LPN #1 stated hands should be washed or sanitized when donning/doffing gloves, between resident care, and as frequently as needed. Continued interview revealed proper hand hygiene was necessary to prevent the spread of infection and keep residents and staff safe. Interview with the Assistant Director of Nursing (ADON), on 09/24/2020 at 2:00 PM, who had been employed at the facility for five (5) years and the Director of Nursing (DON), who had been employed at the facility for one (1) month revealed staff was to use hand sanitizer before and after donning and doffing gloves, and before, between, and after resident care and contacts to prevent the spread of infection. Continued interview with both revealed staff was trained on proper handwashing techniques and hand hygiene. Per interview, the ADON and DON expected staff to follow infection control guidelines and policies strictly to prevent the spread of infection. Interview with the Administrator, on 09/24/2020 at 6:15 PM, revealed she expected staff to follow infection control protocols, policies, procedures, and guidelines to include hand hygiene to prevent the spread of infection to residents and staff. Further, the Administrator said staff should be washing and/or sanitizing their hands between residents and when administering medications.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (2) of twenty-three (23) sampled residents (Resident #45 and Resident #62). Observation on 03/12/19 and 03/14/19, revealed Resident #45 had information posted on the front of his/her room door detailing care needs. In addition, observation on 03/12/19 and 03/13/19, revealed Resident #62 had his/her name labeled in black marker, across the back of his/her sweater, down the outside of his/her pant leg and across the top of his/her socks. The findings include: Review of the facility Policy titled Quality of Life- Dignity, undated, revealed the resident shall be cared for in a manner that promotes and enhances qualify of life, dignity, respect and individuality. Further review of the Policy, revealed the resident(s) shall be treated with dignity and respect at all times. 1. Review of Resident #45's clinical record revealed the facility admitted the resident on 08/01/17 with [DIAGNOSES REDACTED]. The facility assessed Resident #45 in the Quarterly Minimum Data Set (MDS) Assessment, dated 10/15/18, as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Observation on 03/12/19 at 9:30 AM, revealed a plastic sleeve with paper documents inside on the front of Resident #45 door. The following information could be read from the front of the packet without taking the packet out of the plastic sleeve. 1. When giving resident medications, mix with strawberry jam, use small containers; 2. Resident is totally deaf without hearing aides. Not cooperative when they are being removed, especially at night. When inserted, the one with the little hook goes in the left ear, and they must be fully inserted to work. They are new and cost $5000 so we are concerned about them and the possibility of loss. Of course, they must be removed when showering, shampooing. 3. Resident wears watch on left wrist and always wants it on. 4. Resident likes to be dressed in a skirt, no slip required anymore, and matching top, of which resident has many. Also, need to wear a necklace from custom jewelry to match. 5. Resident has no concept of time and place. Resident does not remember that he/she lives in Lexington now. Resident has lived here since 2011, prior to that lived in Pennsylvania for over [AGE] years. 6. Resident's bed must stay as close to the floor as possible so he/she cannot get up on his/her own while in bed. Resident has a lot of strength and can pull himself/ herself out of the bed. Resident will fall. 7. Resident is not good about using walker, unless prompted. Balance is not good, but will take off walking without the walker 8. Resident's gold hoop earrings are always to stay on, along with wedding band and other little ring. 9. Resident's family will change hearing aide batteries. 10. Resident's skin needs to be moisturized daily, even if not showered, very dry skin on arms, hands and legs. Interview with State Registered Nurse Aide (SRNA) #6, on 03/14/19 at 1:27 PM, revealed she had worked at the facility for six (6) years. She stated residents were to be treated with dignity and respect and this included keeping their personal information confidential. She stated Resident #45 required assistance with feeding, and his/her daughter visited daily to assist the resident with feeding and other care. Further interview revealed the resident's daughters posted several notes to make the staff aware of the resident's care needs. She stated the note on the outside of the resident's front door was a list of things the daughter wanted staff to do for the resident daily. SRNA #6 further stated she was not sure of the facility's policy regarding signs related to care needs; however, in her opinion signs related to care needs should not be posted on the outside of the door where it was accessible for all residents, visitors, and staff not involved in his/her care to read. She stated having the sign posted on the resident's door was a dignity issue. Interview with SRNA #5, on 03/14/19 at 2:00 PM, revealed she had worked at the facility since (MONTH) (YEAR). She stated residents were to be treated with respect, and this included providing care in a respectful manner. She further stated the sign posted with specific care needs on the front of Resident #45's door had been on the door since she first started at the facility. Further interview revealed the sign should be posted on the inside of the closet door, on the back of the door, or in a book in the resident's room, where only staff involved with the resident's care had access to the information. She further stated she had wondered about the sign being on the resident's door as it was a dignity issue, but when she asked about the sign, she was told administrative staff was aware of the sign and permitted it to be on the outside of the resident's door. Interview with the Director of Nursing (DON), on 03/14/19 at 4:45 PM, revealed she had been working at the facility since (MONTH) (YEAR). Per interview, it was her expectation for all residents to be treated with respect and dignity. She stated the facility could post signs related to care needs in a discreet location; however, families could make requests to post signs in non-discreet locations. Further interview revealed the facility had several discussions with Resident #45's daughter regarding the signs she posted, but the daughter did not understand the progression of dementia and was adamant the signs were staying because she wanted to be sure staff knew how to care for the resident. Further interview with the DON, on 03/14/19 at 4:47 PM, revealed she wanted to walk to Resident #45's room in order to understand what the dignity issue was, related to the sign. Upon arrival to Resident #45's room, the DON stated she was not aware the sign was posted on the front door as the resident's daughter's signs were usually posted inside the resident's room. The DON stated the sign posted on the front of Resident #45's door was a dignity issue and would be removed immediately. She stated she would be having a conversation with Resident #45's daughter. Interview with the Administrator, on 03/14/19 at 5:13 PM, revealed she had worked at the facility for over ten (10) years and it was her expectation for all staff to uphold the residents' dignity. She stated her definition of dignity would be to uphold the residents' wellbeing, respect, and vision of themselves. Further interview revealed she was unaware of a sign related to care needs being posted on the outside of Resident #45's front door. She stated the resident's daughter asked to post signs and permission was given; however, signs posted on the outside of the front door was a dignity issue. 2. Review of Resident #62's clinical record revealed the facility admitted the resident on 08/22/17 with [DIAGNOSES REDACTED]. The facility assessed Resident #62 in the Quarterly Minimum Data Set (MDS) Assessment, dated 01/29/18 as having a BIMS score of zero (0) out of fifteen (15), indicating severe cognitive impairment. Observation on 03/12/19 at 9:30 AM and 03/13/19 at 10:00 AM, revealed Resident #62's name was labeled in black marker, across the back of his/her sweater, down the outside pant leg and across the top of his/her sock. Interview with SRNA #6, on 03/14/19 at 1:27 PM, revealed when a resident was admitted , a black sharpie pen was used to label their clothes, and sometimes-family members would write names on the clothes. Per interview, staff were instructed to write the residents' names on the inside of the collar or on the tag as residents' names should not be on the outside of clothing for all to see. Further interview revealed the facility had several residents that had their names written on the outside of their clothes and this was a dignity issue. Interview with SRNA #5, on 03/14/19 at 2:00 PM, revealed she was assigned to Resident #62 on 03/12/19, 03/13/19 and 03/14/19, and had dressed the resident on those days. She stated all of Resident #62's sweaters and socks were labeled with his/her name on the outside, and his/her pants had his/her name written down the leg. She further stated the resident's family member labeled the resident's clothes in this manner, and administrative staff was aware. Further interview revealed she had always considered this a dignity issue, but since administration was aware, she assumed it was okay. Interview with Licensed Practical Nurse (LPN) #4, on 03/14/19 at 2:30, revealed she had worked at facility for over a year. Per interview, her definition of dignity was for all residents to be treated with respect and privacy. She stated Resident #62 had worn clothes with his/her name marked on the outside of the clothes since she started at the facility. She stated the family labeled the clothing; however, she felt this was a dignity issue and resident's name should be marked on the inside of the clothing in a inconspicuous place. Interview with the DON, on 03/14/19 at 4:45 PM, revealed, Resident #62's family labeled his/her clothing. She stated she had asked about the resident's name being on the outside of his/her clothing in the past because she thought it was a dignity issue, but she was told it was okay because the family labeled it that way. Per interview, families were educated about labeling of clothing when a resident was admitted , and to be discreet; however, it did not always happen. Interview with the Administrator, on 03/14/19 at 5:17 PM, revealed she was aware of Resident #62's clothing being labeled in black marker on the outside of the resident's clothing. She stated the resident's daughter chose to label the resident's clothing that way. Further interview, revealed upon a resident's admission, staff would review with family, how the clothing was to be marked, in a discreet location; however, the facility had no written policy or procedure related to marking clothing items with resident names. Further interview revealed she understood this was a dignity issue.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to have an effective system in place to ensure the resident's code status was on the Monthly Physician's Orders in the clinical record, for two (2) of nine (9) sampled residents reviewed for Advanced Directives, out of a total of twenty-three (23) sampled residents (Resident #9 and Resident #94). Review of Resident #9 and Resident #94's clinical record revealed the Monthly Physician's Orders did not include code status. The findings include: Review of the facility's Policy titled, Advanced Directives, dated ,[DATE], revealed the facility would respect resident's Advanced Directives (written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated) in accordance with state law and facility policy. Further review of the Policy, revealed the facility would display information as to whether or not the resident has executed an Advanced Directive, prominently in the medical record. Continued review of the Policy, revealed the facility would review annually with the resident, his or her Advanced Directive, to ensure such directives are still the wishes of the resident. However, further review of the Policy, revealed the need for Physician's Orders related to code status was not addressed. Review of the facility's Policy titled, Following Physician's Orders, dated ,[DATE], revealed the Physician would prescribe medications, treatments, advance directives, and other care directives. Further Policy review, revealed the facility would follow Physician's Orders as prescribed. 1. Review of Resident #94's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #94's medical record revealed a white sheet of paper located in the front of the chart with a sticker attached that read, Full Code. Continued review of the clinical record revealed a tab labeled, allergies [REDACTED]. allergies [REDACTED]. Review of the (MONTH) (YEAR) Monthly pre-printed Physician's Orders, revealed orders for Full Code initiated [DATE]. However, review of the (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 Monthly pre-printed Physician's Orders, revealed Resident #94's code status was not reflected on the Orders. 2. Review of Resident #94's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #94's Monthly Physician's Orders for (MONTH) 2019, revealed there was no active orders for the resident's code status. Interview with the Registered Nurse (RN) Supervisor, on [DATE] at 6:16 PM, revealed, she was one (1) of two (2) licensed staff members responsible for completing the change-over at the end of each month when the pharmacy delivered new Medication Administration Records (MARs), Treatment Administration Records (TARs) and the Monthly pre-printed Physician's Orders to the facility. Further interview revealed she and another licensed staff member ensured all Physician's Orders for all residents had been transcribed from the current month's MARs, TARs and Monthly Physician's Orders to the upcoming month's MARs, TARs and Monthly Physician's Orders. Continued interview with the RN Supervisor, revealed the facility began having problems with orders falling off the Monthly Physician's Orders and with orders that had been discontinued showing up on the Monthly Physician's Orders, once a different company bought the facility's Pharmacy. Additional interview revealed these issues were identified on or around October/November (YEAR) and the Director of Nursing (DON) and Administrator were aware of the problem. The RN Supervisor stated nursing staff had identified the code status was missing from the Monthly Physician's Orders and she and other nursing staff were instructed by Pharmacy and the DON to fax code status clarification orders to the Pharmacy. Further interview revealed staff should be able to check the resident's Monthly Physician's Orders to locate the resident's code status in case of an emergency (ie. The resident was found unresponsive with no respirations and no pulse). She stated staff needed code status to be on the Monthly Physician's orders in order to know if Cardiopulmonary Resuscitation (CPR) should be performed in an emergency. Telephone interview with RN #2, on [DATE] at 5:53 PM, revealed at the end of the the month, she reconciled Physician's Orders on the east unit of the facility. She stated it was her responsibility to ensure written or verbal orders from the current month were carried over to the new Physician's Orders, MARs and TARs for the upcoming month during changeover. She further stated the facility changed pharmacies in (MONTH) (YEAR), and the new pharmacy wanted new orders written for the resident's code status before they would print them on the Monthly Physician's Orders. Further interview revealed during changeover, when she noticed there was no code status on the new months Monthly Physician's Orders, she would write in the code status. She further stated there should be an active Physician's Order for code status for each resident. Interview with the Pharmacist, on [DATE] at 6:47 PM, revealed the last facility Pharmacy was bought out by the current Pharmacy in (MONTH) (YEAR) and therefore the Physician's Orders were on a new computer programmed system. Further interview revealed the facility notified the Pharmacy in (MONTH) (YEAR) or (MONTH) (YEAR) of what was found to be some computer-program glitches. Continued interview revealed the Pharmacist was aware staff were reporting some Monthly Physician's Orders were missing some orders and some had old orders on them. Additional interview with the Pharmacist, revealed he was unaware of any current concerns from the facility related to the pre-printed Monthly Physician's Orders following the faxing of clarification orders. The Pharmacist stated the pre-printed Monthly Physician's Orders sent from pharmacy should include code status; however, it was the nurse's responsibility to ensure the Monthly Physician's Orders were correct related to medications, treatments and code status, as per nursing standards of practice. Interview with the Director of Nursing (DON), on [DATE] at 7:07 PM, revealed she was aware some Monthly Physician's Orders did not reflect the residents' code status. She stated she had attempted numerous times to reach the original Pharmacy utilized by the facility, prior to the pharmacy buy-out, in an effort to resolve this issue with no results. Further interview revealed the facility noticed missing information including medication orders and code status on the Monthly Physician's Orders in (MONTH) and (MONTH) (YEAR), just after the pharmacy buy out. The DON stated she and other staff would contact the Pharmacy about these issues and pharmacy would tell them to fax clarification orders to the Pharmacy. She stated, then the Pharmacy would send the corrected Physician's Orders to the facility, but with the incorrect original date for the code status order. The DON stated she and other licensed personnel had discussion after discussion with the Pharmacy, with absolutely no resolution to the issue. Additional interview revealed the DON would be contacting the Pharmacy Manager to discuss a resolution. Further interview revealed a resident's code status should be in the clinical record, and should be current on the Monthly Physician's Orders. Interview with the Administrator, on [DATE] at 5:07 PM, revealed code status should be displayed prominently in the resident's clinical record on the Monthly Physician's Orders to ensure the resident's code status was easily accessible to staff in the unfortunate event of a crisis situation. Further interview revealed she was aware of the concern with code status and the lack of consistency with the Physician's Orders being printed out correctly by the Pharmacy. Continued interview revealed it was an issue the DON, other licensed staff, and she had been working collaboratively on and planned to resolve soon.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure the environment remained free of accident hazards. Observation on 03/12/19, revealed five (5) of eight (8) rooms checked for water temperatures, were identified with water temperatures in excess of 110 degrees Fahrenheit (F), including room [ROOM NUMBER] which had a sink water temperature of 122 degrees F. The findings include: Review of the facility's Policy, titled Water Temperatures, revised 2009, revealed tap water in the facility shall be kept within a temperature range to prevent scalding/burning of residents. Continued review of the Policy, revealed water heaters that service residents' rooms, bathrooms, common areas, and tub/showers areas shall be set to temperatures that will not cause scalding/burning. Review of the facility Daily Audits Water Temperature Log, for temperatures obtained for the months of January, (MONTH) and (MONTH) 2019, revealed temperatures ranging between 101 and 110 degrees F. Observation on 03/12/19 at 10:00 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 118 degrees F (high), using the Office of Inspector General (OIG) State Agency Representative's thermometer, Observation on 03/12/19 at 10:04 AM, in room [ROOM NUMBER] room, revealed the bathroom sink water temperature was 118 degrees F (high), using the OIG thermometer, Interview on 03/12/19 at 3:05 PM, with the Maintenance Director, revealed to his knowledge, all water temperatures had been within a normal range of 100-110 degrees F. He stated he was unaware of water temperatures being higher than 110 degrees F. Observation on 03/12/19 at 3:12 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 110 degrees F, using a facility dial thermometer. Observation on 03/12/19 at 3:15 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 92 degrees F, (low), using a facility dial thermometer Observation on 03/12/19 at 3:18 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 100 degrees F, using a facility dial thermometer Observation on 03/12/19 at 3:18 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 100 degrees F, using a facility dial thermometer. Observation on 03/12/19 at 3:21 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature at 102 degrees, using a facility dial thermometer. Observation on 03/12/19 at 3:23 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 102 degrees F, using a facility dial thermometer. Interview was conducted on 03/12/19 at 3:40 PM, with the Administrator and Maintenance Director, regarding the discrepancies between temperature readings from the OIG thermometer and temperature readings from the facility thermometer. The Maintenance Director stated he did not always calibrate his thermometer before obtaining water temperatures, but he did calibrate the thermometers from time to time by immersing the thermometers in cold water until they reached 32 degrees F. Observation revealed, the Administrator retrieved a digital thermometer from the desk drawer and gave it to the Maintenance Director. Both the digital thermometer and the original facility thermometer were submersed into a cup of ice water designated for testing the thermometers. The temperature for both thermometers read thirty-two (32) degrees. Observation on 03/12/19 at 3:55 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 119 degrees F (high), using the facility digital thermometer. Observation on 03/12/19 at 4:00 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 108 degrees F, using the facility digital thermometer. Observation on 03/12/19 at 4:05 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 120 degrees F, using the facility digital thermometer. Observation on 03/12/19 at 4:07 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 122 degrees F, (high), using the facility digital thermometer. Observation on 03/12/19 at 4:11 PM in room [ROOM NUMBER], revealed the bathroom sink water temperature was 113 degrees F, (high), using the facility digital thermometer. Observation on 03/12/19 at 4:13 PM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 103 degrees F, using the facility digital thermometer. Observation on 03/12/19 at 4:15 PM in room [ROOM NUMBER], revealed the bathroom sink water temperature was 117 degrees F (high), using the facility digital thermometer. Observation on 03/12/19 at 4:18 PM in room [ROOM NUMBER], revealed the bathroom sink water temperature was 100 degrees F, using the facility digital thermometer. Interview on 03/12/19 at 4:35 PM, with the Maintenance Director, revealed the hot water heater temperature had been turned down and he was going to purchase a new digital thermometer in the morning and do a recheck of the water temperatures. Observation on 03/13/19 at 10:48 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 105 degrees F, using the facility digital thermometer. Observation on 03/13/19 at 10:49 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 111 degrees F, using the facility digital thermometer. Observation on 03/13/19 at 10:51 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 109 degrees F, using the facility digital thermometer. Observation on 03/13/19 at 10:52 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 110 degrees F, using the facility digital thermometer. Observation on 03/13/19 at 10:56 AM, in room [ROOM NUMBER], revealed the bathroom sink water temperature was 103 degrees F, using the facility digital thermometer. Interview on 03/14/19 at 3:05 PM, with Licensed Practical Nurse (LPN) #4, revealed she had not noticed water being too hot in resident rooms. Per interview, in the past residents had reported when water temperatures were not hot enough, but nobody had complained of hot water temperatures. She stated she could contact the Maintenance Director anytime, day or night, if the water temperatures were too hot or too cold. Interview on 03/14/19 at 03:14 PM, with State Registered Nurse Aide ( SRNA) # 7, revealed when residents were assisted with showers, she would feel the water herself and then have the residents feel the water to make sure it was comfortable before assisting the resident into the shower. Further interview revealed if the water was too hot, it could burn the residents. Interview on 03/14/19 at 3:45 PM, with the Maintenance Director, revealed he checked water temperatures from resident room sinks, checked the water heater thermostat readings, and checked the water heater valves to make sure there were no leaks, daily. He stated, he tried to keep the water temperature between 105 degrees F and 120 degrees F, with the goal of keeping the water temperatures at 110 degrees F. Furher interview revealed he regulated the water temperatures by adjusting the thermostat on the water heater and going back to check temperatures of water faucets in different parts of the facility after waiting fifteen (15) to thirty (30) minutes. The Maintenance Director stated he could call the company who provided maintenance services on facility equipment, if needed. Further interview revealed he was unaware the thermometer he had been using to obtain water temperatures was not working properly. Interview on 03/14/19 at 5:13 PM, with the Administrator, revealed she was not aware that the thermometer the Maintenance Director was using to test water temperatures was not working properly. Per interview, it was her expectation water be at safe and comfortable temperature ranges to ensure residents were not scalded or burned. Further interview, revealed it was her expectation staff report temperatures that were too cold or too hot for washing and bathing to the Maintenance Director.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of four (4) sampled residents reviewed for infections out of a total of twenty-three (23) sampled residents (Resident #94). Observation on 03/14/19, revealed State Registered Nursing Assistant (SRNA) #8 entered Resident #94's room and failed to wash hands and don gloves prior to repositioning the resident in the bed. Further, SRNA #8 then touched the resident's face and hair with her bare hands while talking to the resident. After providing care, SRNA #8 proceeded to exit the resident's room without performing hand hygiene. The findings include: Review of the facility's Policy titled, Handwashing, dated 09/02/14, revealed handwashing with soap and water was the best approach to hand hygiene. Further review revealed handwashing would be performed promptly following any situation during which microbial contamination of hands was likely to occur (even when gloves were worn) and as promptly and as thoroughly as possible between resident contacts as well as between tasks and procedures on the same resident to prevent cross contamination. Continued review of facility's Policy, revealed handwashing would be performed after gloves have been removed and when otherwise indicated to avoid transfer of microorganisms to other residents and environments. Review of the facility's Policy titled, Infection Control, dated 09/02/14, revealed the purpose of the facility's policies and practices were intended to facilitate the maintenance of a safe, sanitary and comfortable environment and to help prevent and manage the transmission of diseases and infections. Further review revealed the primary objective for the facility's infection control policies and practices was to prevent, detect, investigate and control infections. Continued review revealed the facility would prevent infections among its resident population by utilizing proper infection control procedures that included, but were not limited to handwashing, and utilization of protective personal equipment. Additional review of the Policy, revealed all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. 1. Review of Resident #94's clinical record revealed the facility readmitted the resident on 10/10/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/18/19, revealed the facility was unable to conduct a Brief Interview for Mental Status (BIMS), but assessed the resident as having severe cognitive impairment and as unable to participate in decision-making regarding tasks of daily life. Further review of the Quarterly MDS Assessment, revealed the facility assessed the resident as requiring total physical dependence of one (1) staff member for bed mobility, locomotion on/off unit, dressing, eating, toileting and personal hygiene. Observation on 03/14/19 at 8:25 AM, revealed State Registered Nursing Assistant (SRNA) #8 and Licensed Practical Nurse (LPN) #1 entered Resident #94's room to prepare him/her for medication administration and bolus tube feeding. SRNA #8 failed to provide hand hygiene or don gloves before assisting the resident to reposition by holding the resident's right arm, shoulder and hip area, and then repositioning the resident to an upright position. Further observation revealed SRNA #8 touched the resident's bed with both bare hands and then touched Resident #94's hair and face as she spoke with the resident at the bedside. Continued observation revealed SRNA #8 stroked the resident's hair and talked with the resident about his/her likes/dislikes and preferences regarding daily care. Additional observation revealed SRNA repositioned the resident's bed linens, and then exited the resident's room without washing or sanitizing her hands. Interview with SRNA #8, on 03/14/19 at 8:36 AM, revealed she was assigned to provide care for Resident #94. SRNA #8 stated she should have washed and/or sanitized her hands prior to entering the resident's room or prior to providing care for the resident for infection control purposes. Further interview with SRNA #8, revealed she should have ensured she was wearing gloves to protect the resident and herself from cross-contamination while providing care, as this was an infection control issue/topic staff was provided information and training about constantly. Continued interview revealed cross-contamination was the transfer of germs or microorganisms from one person or surface to another person or surface. Additional interview revealed she should have washed her hands prior to exiting the resident's room for the same reason; to prevent the spread of germs to others, including herself, other residents and staff members. SRNA #8 stated she was in a hurry to assist LPN #1 and wasn't thinking. Interview with LPN #1, who was assigned to administer medications and treatments to Resident #94, on 03/14/19 at 9:45 AM, revealed SRNA #8 should have washed her hands and donned gloves prior to providing care to Resident #94. Further interview revealed SRNA #8 should have worn gloves while providing care to Resident #94 as a standard precaution for infection control. LPN #1 further stated, SRNA #8 should have completed care for Resident #94 by removing her gloves and washing her hands before exiting the resident's room to prevent the potential spread of germs, illness, diseases and/or infection to other facility residents, employees, visitors/family members and anyone else coming into or leaving from the facility. Additional interview with LPN #1, revealed staff should be familiar with infection control policies/practices and procedures to prevent illness, disease and infections amongst the vulnerable population. Interview on 03/14/19 at 10:00 AM, with LPN#1/ Charge Nurse, revealed SRNA #8 should have washed her hands and donned gloves prior to providing care to Resident #94. Further interview revealed SRNA #8 should have removed her gloves and washed her hands upon completion of care and prior to exiting Resident #94's room. Continued interview revealed she expected all staff to follow the facility's policies and practices related to infection control. Additional interview revealed it was her expectation hand washing be a priority for all staff. Interview with the Director of Nursing (DON), on 03/14/19 at 7:05 PM, revealed SRNA #8 should have washed her hands prior to entering Resident #94's room and prior to exiting the resident's room. Further interview revealed SRNA #8 should have donned gloves before providing care to Resident #94. Continued interview revealed it was the DON's expectation that staff adhere to the facility's infection control policies and practices, and ensure proper hand hygiene and glove usage when providing direct resident care. Interview with the Administrator, on 03/14/19 at 7:30 PM, revealed it was her expectation staff maintain proper hand hygiene and glove usage when providing direct resident care. Further interview revealed it was also her expectation staff be familiar with facility infection control practices and procedures and know the process of cross contamination.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure residents were treated with respect and dignity in a manner that promoted maintenance or enhancement of his or her quality of life for one (1) of twenty-six (26) sampled residents, Resident #61. Observation, on 02/26/18 at 3:40 PM, revealed a State Registered Nursing Aide (SRNA) was standing over Resident #61 while assisting the resident with a snack. The findings include: Review of the facility policy, titled Resident Rights, revised 08/09, revealed the facility would make every effort to assist each resident in exercising his/her rights to assure the resident was always treated with respect, kindness, and dignity. Review of the facility Policy, titled Quality of Life - Dignity, revised 08/09, revealed each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. Continued review revealed residents should be treated with dignity and respect at all times. Further review revealed, treated with dignity meant the resident would be assisted in maintaining and enhancing his/her self esteem and self worth. Per the Policy, demeaning practices and standards of care that compromised dignity were prohibited. Staff would promote dignity. Review of Resident #61's clinical record revealed the facility admitted the resident on 01/29/16 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 01/12/18, revealed the facility assessed Resident #61 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS, revealed the facility assessed Resident #61 to require one (1)person physical assist for eating. Observation of Resident #61, on 02/26/18 at 3:40 PM, revealed the resident was being assisted to eat an afternoon snack. Continued observation revealed Resident #61 was lying in the bed with SRNA #1 standing over the resident and assisting the resident with chocolate pudding and thickened orange juice. Interview with SRNA #1, on 02/26/18 at 3:40 PM, revealed she did not have a consistent resident assignment; however, had worked with Resident #61 previously and was aware of the resident's needs. Continued interview revealed, she was unaware she should be sitting with the resident and not standing over the resident to eat; however, did feel it could be a dignity issue. Interview with Unit Manager #1, on 02/28/18 at 11:10 AM, revealed staff should be in a seated position while assisting residents with meals to ensure resident dignity and respect. Further interview with Unit Manager #1 , revealed standing over a resident while assisting the resident at meal time could make the resident feel rushed and uncomfortable, leading to resident refusal to eat that could later result in weight loss. Interview with the Director of Nursing (DON), on 03/01/18 at 10:30 AM, revealed it was her expectation that staff follow policy when caring for the residents at the facility. Per interview, it was extremely important for the residents to be treated with dignity and respect at all times. Further interview revealed the DON expected the facility staff to remain in a seated position; speak with the residents at eye level; and limit conversation between staff while assisting residents with meal service. Per interview, this was to maintain resident's dignity and respect and enhance their quality of life. Interview with the Administrator, on 03/01/18 at 4:10 PM, revealed it was her expectation that staff follow policy and procedure when assisting residents with meals. She revealed all residents were expected to be treated with dignity and respect in her facility. Further interview revealed the Administrator expected staff to remain in a seated position and have conversations with only the residents being assisted at meals; not one another; because this was a dignity issue.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for each resident to assist in attaining or maintaining the residents' highest practicable quality of life for one (1) of twenty-two (22) sampled residents, (Resident #33). Residents #33 had bilateral upper extremity limited range of motion (ROM) and contractures to his/her hands and physician's orders [REDACTED]. However, the resident was not Care Planned for the palm protectors and observation from 02/26/18 through 03/01/18, revealed the resident was not wearing palm protectors. The findings include: Review of the facility's Care Plans-Comprehensive Policy, revised in (MONTH) 2010, revealed Comprehensive Care Plans were developed and maintained for each resident to identify the highest level of functioning the resident may be expected to attain. Comprehensive Care Plans were designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. Review of Resident #33's clinical record revealed the facility readmitted the resident on 04/13/17 with [DIAGNOSES REDACTED]. Review of Resident #33's Physician Orders, dated (MONTH) (YEAR), revealed orders with an original order date of 06/23/17, for the resident to wear bilateral palm protectors, on every morning and off every evening. Review of Resident #33's Annual Minimum Data Set (MDS) Assessment, dated 12/20/17, revealed the facility assessed the resident to have severe cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as having functional limitations in Range of Motion (ROM), impairment on both sides to upper extremities, and impairment on both sides to lower extremities. Review of Resident #33's Care Area Assessment (CAA), dated 12/20/17, revealed the resident's functional limitations in ROM, impairment on both sides, upper and lower extremities, or palm protectors were not identified in the analysis of findings. Review of Resident #33's Comprehensive Plan of Care, revised 01/02/18, revealed the resident required assistance with Activities of Daily Living (ADLs) related to decreased cognition and physical abilities with a goal that the resident would be appropriately dressed and clean. There were several interventions including: gentle ROM during daily care giving, and Therapy screen/evaluation/treat per physician's orders [REDACTED]. Review of Resident #33's Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed the resident was to have bilateral palm protectors, on every morning and off every evening. This intervention was initialed daily to indicate the intervention had been completed for the month of (MONTH) until 01/23/18. On 01/23/18, the nurse's initials were circled and documentation on the back side of the TAR, revealed sent to emergency room . No initials were documented for the rest of (MONTH) (YEAR) on the TAR related to the intervention for palm protectors. Further review revealed the (MONTH) (YEAR) TAR was signed daily indicating the bilateral palm protectors were provided to the resident per physician's orders [REDACTED]. However, observation on 02/26/18 at 11:40 AM, revealed Resident #33 was lying on his/her back in the bed and the residents bilateral hands were contracted with no palm protectors in place. Also, observation on 02/26/18 at 12:30 PM, 1:30 PM, and at 3:29 PM, revealed Resident #33 was in the bed and did not have palm protectors in place. Observation on 02/27/18 at 8:39 AM, 8:44 AM, 9:04 AM, revealed the resident was in bed and the palm protectors were not on the resident's hands. In addition, observation of the resident on 02/28/18 every two (2) hours from morning through the afternoon hours and observation of the resident on 03/01/18 at 9:00 AM and 10:00 AM, revealed the resident had no palm protectors in place. Interview on 03/01/18, at 10:10 AM, with State Registered Nursing Assistant (SRNA) #4, revealed she was very familiar with Resident #33's care needs; and was assigned to the resident everyday she was scheduled to work. She stated she cleaned the resident's hands daily with soap and water, kept the resident's nails clipped and clean, and opened the resident's hands. Per interview, during care, she performed passive ROM to the resident's arms, and leg. She further stated the resident used to have hand protectors in his/her room which were worn daily; however, they were not in the resident's room now and had been gone about a week. Per interview, she told a nurse when she noticed they were not in the room, but was not able to recall which nurse she informed. SRNA #4 revealed she knew hand protectors were kept in the therapy department; however, did not go to Therapy to request them for Resident #33. Interview on 03/01/18, at 10:24 am, with SRNA #6, revealed she was familiar with Resident # 33, and performed ROM during care to Resident #33's arms and legs, massaged and cleaned the resident's hands with a soapy rag and then dried each hand. Additional interview revealed she was unaware Resident #33 wore palm protectors to his/her bilateral hands and had never seen the resident wear them. Interview on 03/01/18, at 10:31 AM, with Licensed Practical Nurse (LPN) #2, who was assigned to Resident # 33 on 02/28/18 and 03/01/18, revealed she was usually not assigned to Resident #33, but had been assigned to him/her the past few days. Per interview, the aides were attentive to the resident and provided ROM to his/her arms and legs. She stated she had also provided ROM to Resident # 33, including his/her hands because they were contracted. Additional interview revealed she had seen the resident with palm proctors on both hands before and was not sure why palm protectors had not been in place this week as per physician's orders [REDACTED].#2 revealed she did not think the intervention for palm protectors was on the TAR. However, further review of the TAR, revealed the TAR had been signed 02/28/18 and 03/01/18, on the days LPN #2 was assigned to the resident, indicating the resident was wearing the palm protectors. Interview on 03/01/18, at 10:58 AM, with Registered Nurse (RN) #1/Minimum Data set (MDS) Coordinator, revealed palm protectors should have been on Resident #33's Care Plan as it was a physician's orders [REDACTED]. She further stated when therapy discontinued a resident from skilled therapy a referral, with a plan, was sent to Restorative Nursing, and then Restorative Nursing was to implement a Rehabilitative Nursing Care Program. Per interview, she was not sure if there was a program for residents to maintain their current abilities if not referred from therapy, but would check into it and get back with the State Survey Representative. Additional interview on 03/01/18, at 11:22 AM, with RN #1/MDS Coordinator, revealed she called RN #2/Restorative RN, and inquired about palm protectors and restorative programing for Resident #33. She stated Resident #33 was not in a restorative program and the facility did not have a current maintenance program at this time for residents who were not referred from Therapy. However, RN #1/MDS Coordinator revealed the palm protectors, should be included in the Nursing Care Plans. Interview on 03/01/18, at 01:52 PM, with Occupational Therapist (OT) #2, revealed Resident #33's OT related to wheelchair positioning ended in (MONTH) (YEAR). She stated she recalled nursing staff pointing out to her that Resident # 33's right hand fingernails were pushing into the skin on his/her palm at the time the resident was being evaluated for wheelchair positioning, so she issued palm protectors to Resident # 33 that same day. However, she revealed she did not have a Screening or Evaluation Note related to the assessment of contractures or palm protectors from (MONTH) of (YEAR) for Resident #33. She further stated Resident #33 was at risk for compromised skin integrity if palm protectors were not worn, and hand contractures could worsen. Interview on 03/01/18, at 01:33 PM, with the Director of Nursing (DON), revealed nursing staff was to ensure physician's orders [REDACTED].#33 should have been wearing the palm protectors. Per interview, nursing should have ensured the intervention for palm protectors was on the Care Plan. Interview on 03/01/18, at 02:54 PM, with the Administrator, revealed devices such as palm protectors should be Care Planned to be applied and removed per Physician orders.

Based on observation, interview, record review, review of the facility's policy and procedures, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, dated [DATE], it was determined the facility failed to have an effective system to ensure each residents' Comprehensive Care Plan was revised to accurately reflect the residents' current status for one (1) of eight sampled Residents (Resident #1). Resident #1 had a [DIAGNOSES REDACTED]. The Speech Therapy recommendations dated [DATE] and [DATE], revealed the resident was safe with Pureed Diet and Nectar Thick Liquids with staff supervision, but required close supervision for oral intake. However, the Comprehensive Care Plan was not revised to include the recommendation for close supervision with oral intake. On [DATE], at approximately 3:30 PM, Resident #1 was observed by a nurse to have a sandwich in his/her hand, and upon further inspection of the sandwich, the nurse noticed a bite missing from the sandwich. The nurse took the sandwich and assisted the resident to a chair. Shortly afterward, Resident #1 was observed to be choking, and after several unsuccessful [MEDICATION NAME] Maneuver attempts, the resident expired on [DATE] at 3:48 PM. (Refer to F-323) The facility's failure to ensure the Comprehensive Care Plan was revised to reflect the residents' current status has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (A(NAME)) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. On [DATE], the State Survey Agency verified the Immediate Jeopardy was removed on [DATE], as alleged, with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F-280 at a Scope and Severity (S/S) of a D while the facility develops and implements the Plan of Correction (P(NAME)) and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure Comprehensive Care Plans are revised. The findings include: Review of the facility's Development of a Care Plan Policy, undated, revealed the care plan was to be reviewed/revised as per the Resident Assessment Instrument (RAI) Manual with significant changes, and changes in orders as received by the Minimum Data Set (MDS) Coordinator. Continued review revealed the care plan would include non-compliance and unsafe behaviors. Additional review revealed care plan updates/changes were to be done in accordance with the RAI Manual as part of an ongoing process. Review of the Center's for Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, dated [DATE], chapter four (4.7), revealed the Comprehensive Care Plan was an interdisciplinary communication tool, and must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each residents' plan of care. Review of the facility's Therapeutic Diet Policy, revised [DATE], revealed therapeutic diets would be prescribed by the Attending Physician. Mechanically altered diets, as well as diets modified for medical or nutritional needs would be considered therapeutic diets. Continued review of the Policy, revealed the Clinical Dietician, nursing staff, and attending Physician would review, along with other orders, the need for, and resident acceptance of, prescribed therapeutic diets. The clinical dietician, and nursing staff would document significant information relating to a resident's response to his/her therapeutic diet in the resident's medical record. Further review revealed any snacks provided must be compatible with the therapeutic diet. Review of Resident #1's medical record, revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS, revealed the facility assessed Resident #1's eating performance as independent with support of set up help only. Per the MDS, the facility assessed the resident as receiving a mechanically altered diet (specifically prepared to alter the consistency of food in order to facilitate oral intake), and as receiving a therapeutic diet. Review of Resident #1's Nurse's Note, dated [DATE] at 2:00 AM, revealed the resident was receiving a new diet of Nectar Thick Liquids due to having a coughing episode with thin water. Review of the physician's orders [REDACTED]. Review of the Speech Therapy (ST) Evaluation, dated [DATE], revealed the reason for the ST referral was a recent episode of coughing and choking on thin liquids requiring skilled intervention to determine the safest, least restrictive diet level. Further review revealed an analysis of behaviors impacting safety included: reduced attention to task; inattention to bolus; inattention to presentation; impulsive rate; unsafe intake amounts with decreased self-correction; poor self-monitoring skills; and decreased safety awareness. Additional review, revealed ST recommendations for close supervision with oral intake. Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review of the MDS, revealed the facility assessed Resident #1's eating performance as independent with support of set up help only. Continued review of the MDS, revealed the facility assessed the resident as receiving a mechanically altered diet and as receiving a therapeutic diet. Review of Resident #1's Comprehensive Plan of Care, revised [DATE], revealed the resident was at risk for complications and/or injury related to impulsive behaviors, agitation and refusing medication. The goal stated the resident would have no injury/complications related to behaviors. The interventions included: assess resident and try to find out circumstances behind behavior; and encourage diversion activities when resident having behaviors. A new intervention was added on [DATE], after the resident had the choking/coughing episode which stated the resident had a diet and fluid change and to be observant of the resident seeking out regular consistency food/fluids and offer appropriate consistency snacks. Further review of Resident #1's Nutritional Comprehensive Plan of Care, revised [DATE], revealed the resident was at nutritional risk related to receiving a mechanically altered pureed diet related to Dysphasia (difficulty swallowing). The goal stated the resident would have no significant weight loss and would tolerate diet. There were several Care Plan interventions including: change diet consistency to pureed; nosey cup (adaptive drinking cup with cut out for the nose) for all nectar thick liquids; provide, encourage, and assist as needed with diet and fluids; diet per Medical Doctor order; assist with meals according to daily care plan; and be alert for chewing and or swallowing precautions. However, further review revealed there was no documented evidence the Care Plan was revised after the ST recommendation of close supervision for oral intake as per the ST Evaluation dated [DATE]. Review of Resident #1's Speech Therapy Discharge Summary, dated [DATE], revealed the resident was seen for Dysphagia Therapy and was safe with pureed foods, but required close supervision due to impulsive behaviors. The section under Patient and Caregiver Training, revealed Resident #1 was unable to cognitively carry over skilled safety precautions and would need to remain on Nectar Thick Liquids. This and safety precautions relayed to staff. The section titled, Discharge Status and Recommendations, revealed the resident was safe with Pureed Diet and Nectar Thick Liquids with staff supervision, but required close supervision for oral intake. Review of Resident #1's Verbal physician's orders [REDACTED]. However, the recommendations per the Speech Therapy Discharge Summary, dated [DATE], for close supervision with oral intake, were not written into the orders. Further review of Resident #1's current Comprehensive Care Plan, revised [DATE], revealed there was no documented evidence the Care Plan was revised after the ST Discharge Summary, dated [DATE], with recommendations for close supervision for oral intake. Review of Resident #1's State Registered Nurse Aide (SRNA) [DATE] Daily Care Plan Record, revealed under the Diet Section, interventions for : set up help only; dining room for breakfast, lunch and dinner; assistive device of scoop plate and nosey cup; Nectar Thick Fluids; no water pitcher; and no straw. However, there was no documented evidence Resident #1 was on swallowing precautions or required close supervision with oral intake. Review of the facility's Five (5) day Follow up and Investigation Report, dated [DATE], revealed on [DATE] at approximately 3:25 PM, Resident #1 was seen with a sandwich, and the nurse immediately intervened, removed the sandwich, and visually checked the resident's oral cavity with no food particles seen. Per the Report the resident was in no distress and the nurse assisted the resident to sit down. The nurse turned to get the resident a different snack when Resident #1 stood up. Per the Report, Resident #1's knees started to buckle when another nurse assisted the resident to the floor. Further review of the Report, revealed the other nurse thought the resident was having a [MEDICAL CONDITION] as the resident had a history of [REDACTED]. Resident #1 was unresponsive and skin was cyanotic (bluish color due to lack of oxygen in the blood); abdominal thrusts were initiated; and 911 was called. Additional review of the Report, revealed abdominal thrusts, oral suction, and oxygen therapy continued until Emergency Medical Services (EMS) arrived. According to the Report, when EMS arrived, they verified Do Not Resuscitate (DNR) code status, and verified absence of a pulse and respirations and the resident was pronounced dead. Review of the Nurse's Note, dated [DATE] at 4:15 PM, signed by Licensed Practical Nurse (LPN) #4, revealed upon return to the nurse's station, she observed Resident #1 standing in the middle of the hall with a sandwich in hand. Per the Note, LPN #4 confiscated the sandwich and upon further inspection, noticed a bite missing from the sandwich and assessed the resident's mouth for food particles, and none were noted. Continued review of the Note, revealed Resident #1 appeared to be without signs and symptoms of respiratory distress and LPN #4 redirected the resident to a chair in the day area and assisted the resident to a seated position. According to the Note, LPN #4 had her back to the resident and when she turned around she observed LPN #3 and State Registered Nurse Aide (SRNA #6) attempting to prevent Resident #1 from falling forward. Additional review of the Note, revealed LPN #4 assisted staff with getting the resident back into the chair. Per the Note, LPN #3 stated the resident was turning purple, and two (2) staff members stayed with the resident at the chair while LPN #3 verified the resident's code status as Do Not Resuscitate (DNR). Additional review of the Note, revealed 911 was called at 3:36 PM and Resident #1 was assisted to the floor in a lying position. The resident's body was noted to be very rigid and the resident's tongue was very thick. Abdominal thrusts, mouth sweeps, suction, and oxygen therapy were provided. Continued review of the Note, revealed staff provided several repeated rounds of abdominal thrusts and mouth sweeps until Emergency Medical Services (EMS) arrived and attached [MEDICATION NAME] and a portable heart monitor to the resident. Per the Note, after EMS placed the resident on the monitor, the resident was noted to have asystole (absence of a heart beat), and EMS notified the Coroner and remained with the body until the Coroner arrived. Review of the Coroner's Report, dated [DATE], revealed Resident #1 was pronounced dead on [DATE], with immediate cause of resulting death as obstruction of airway, with choking listed as a sequential condition leading to the cause of death. Interview on [DATE] at 9:18 AM, with LPN #4, who worked the 7:00 AM to 7:00 PM shift on the East Unit where Resident #1 resided on [DATE], revealed she was clocking back in from lunch when she saw Resident #1 with a sandwich in hand. Per interview, when she took the sandwich away from the resident, she noticed there was a bite missing from the sandwich. LPN #4 stated she assisted Resident #1 to sit down, checked the resident's mouth for food, and when she did not see any, she turned around to get the resident an appropriate snack. LPN #4 further stated her back was to the resident, and she heard a commotion from behind her. She stated when she turned around she saw LPN #3 and SRNA #6 attempting to assist the resident because it looked like the resident was going to fall. Further interview with LPN #4, revealed LPN #3 and SRNA #6 assisted Resident #1 to the chair, and LPN #3 yelled out, the resident was purple. Per interview, LPN #4 helped put the resident on the floor, and began the [MEDICATION NAME] Maneuver while LPN #3 yelled out to call 911 and ran to the desk to check the resident's code status. Further interview with LPN #4, revealed staff hooked the resident up to oxygen, and tried to suction the resident's mouth and got out what looked like part of a turkey sandwich. Per interview, staff kept doing the [MEDICATION NAME] Maneuver and sweeping the resident's mouth for food until the ambulance and fire department arrived. LPN #4 stated, when EMS placed the [MEDICATION NAME] and turned on the heart monitor they said the resident was in asystole and then pronounced the resident dead. Additional interview with LPN #4, revealed the dietary department had delivered the snack cart to the unit while she was at lunch and placed it behind the nurse's station. She stated, Resident #1 probably got the sandwich from the snack cart because the resident had a history of [REDACTED]. Per interview, the snack cart should not have been left unsupervised or unattended because residents could take food or snacks that could harm them. Interview on [DATE] at 11:05 AM, with LPN #2, who typically worked the 7:00 AM to 3:00 PM, on the East Hall, revealed Resident #1 wandered everywhere and would go behind the nurse's station. LPN #2 stated staff had to hide water pitchers due to Resident #1 taking them off the medication carts. LPN #2 further stated she had to take food away from the resident several times because the food was not the correct diet or consistency. Further interview revealed she was sure there were times the snack cart was left behind the nurse's station unsupervised. Continued interview revealed LPN #2 was working the day Resident #1 choked and died . She stated she was aware the resident required supervision because the resident was always taking food from wherever he/she could get it, but was not aware the resident required close supervision with oral intake. LPN #2 stated the Comprehensive Care Plan and the SRNA Daily Care Plan Record, guided staff in what kind of care each resident required. She stated the Care Plan and the SRNA Daily Care Plan Record should have been updated to reflect Resident #1's need for close supervision with oral intake. Additional interview revealed the MDS Coordinator and the DON were responsible for updating the Care Plans. Interview on [DATE] at 8:15 PM, with SRNA #6, who typically worked weekends from 7:00 AM to 7:00 PM on the East Hall, revealed dietary staff would drop the snack carts off outside the nurse's station and when staff noticed the carts, they would pass out snacks to their assigned residents. SRNA #6 revealed, when the carts were left unattended residents and visitors would just help themselves to the snacks, even if it wasn't their snack. SRNA #6 further stated Resident #1 was always walking up and down the halls with his/her walker and if he/she saw any food or drinks anywhere, he/she would just grab it and say mine, mine. Per interview with SRNA #6, Resident #1 would take food and drinks away from other residents. Interview on [DATE] at 4:10 PM, with the Dietary Aide who delivered the snack cart to the East Unit at approximately 3:00 PM on [DATE], the day of the incident, revealed she delivered the snack carts to the units and asked whoever she saw if it was okay to leave the cart behind the nurse's station, and then she went back to the kitchen. She further stated she did not know if the snack cart was left unattended after she dropped it off on [DATE], and did not know remember who she had asked about leaving the snack cart at the nurse's station that day. Per interview, she had seen snack carts sitting outside the nurse's station unattended after snacks were passed with trash and sometimes unopened snacks on the cart. Interview on [DATE] at 4:40 PM, with the Director of Food and Nutrition Services, revealed snack carts were delivered to the units by the dietary staff three (3) times a day, and the carts were not to be left unattended by facility staff because there were residents who were mobile in the facility who might have dietary restrictions and they could be at risk for harm if the carts were left unsupervised. Interview on [DATE] at 6:45 PM, with Speech Therapist #1 (ST), revealed Resident #1 required close supervision with the rate and amount of food intake because he/she could not judge a reasonable amount of food intake due to his/her impulsive behavior while eating. The ST stated Resident #1 would often take large bites, was fast paced while eating, and did not chew the food adequately before swallowing, putting the resident at risk for choking. Continued interview revealed the resident needed supervision and cueing while eating with instructions to slow down, take smaller bites, and to chew adequately. She stated the resident would do very well when cued and supervised. Additional interview with ST #1, revealed she wrote the physician's orders [REDACTED].#1's speech therapy and to continue with a Pureed Diet with Nectar Thick Liquids. However, she stated she did not verbally communicate to the nursing staff that the resident required close supervision with oral intake and she did not write for the resident to have close supervision for oral intake on the physician's orders [REDACTED].#1, she she probably should have communicated the close supervision with oral intake to the nurse on the unit and she should have written it on the physician's orders [REDACTED]. Per interview, when she wrote the ST Discharge Summary for Resident #1 on [DATE], she just filed the recommendations in the record. Interview on [DATE] at 3:00 PM, with MDS Coordinator #2, who was responsible for completing the MDS Assessments and updating the Care Plans on the East Hall, revealed Resident #1 had a history of [REDACTED]. Per interview, Resident #1's Comprehensive Care Plan should have had appropriate interventions in place to assist staff in how to care for the resident due to food seeking behaviors. Further interview with MDS #2, revealed the ST did not make nursing aware the Resident #1 required close supervision with oral intake. Per interview, had nursing been aware, the Care Plan could have been updated to reflect the residents need for close supervision with oral intake. Additional interview revealed all staff were responsible for providing supervision to the residents and the snack carts should be supervised to prevent residents from getting food items that were not appropriate for their prescribed diet. Interview on [DATE] at 3:15 PM with the Assistant Director of Nursing (ADON), revealed the Comprehensive Care Plan was located in every residents' chart and was updated or revised annually, quarterly, or anytime there were any changes, and could be updated or revised by any nurse. Per interview, anytime a physician's orders [REDACTED]. Additional interview revealed, the SRNA's had a SRNA Daily Care Plan Record that was updated by the MDS coordinators whenever there were changes. Per interview the SRNA Daily Care Plan Records were printed every day and placed at the nurse's station and the SRNA's were required to take one at the beginning of their shift so they would know what type of care their assigned resident's needed. Per interview, she expected the ST to write orders for any recommendations and she expected the Comprehensive Care Plans and the SRNA Daily Care Plan Records to be revised to reflect those recommendations. Additionally, the ADON revealed the ST recommendations for Resident #1 to have close supervision with oral intake should have been conveyed to nursing and the Comprehensive Care Plan as well as the SRNA Daily Care Plan Record should have been revised to reflect this intervention. Interview on [DATE] at 4:22 PM, with the Director of Nursing (DON), revealed if Resident #1 required close supervision with oral intake, the resident should not have had access to food unsupervised. Per interview, if a resident required close supervision with oral intake, staff should provide the supervision needed, and if a resident required supervision during meals, she also expected staff to be observant and supervise those residents during snack consumption as well. Further interview revealed Resident #1's ST recommendations for close supervision for oral intake should have been clearly verbally communicated to nursing staff , and should have been written as a physician's orders [REDACTED].#1's Comprehensive Care Plan and the SRNA Daily Care Plan Record should have been revised to include the intervention for close supervision with oral intake. She stated the care plan should reflect all care and services a resident required so staff could meet each resident's individualized needs accordingly. Further interview revealed she expected staff to follow the facility's policy for updating and revising the care plan. Interview on [DATE] at 1:50 PM with the Attending Physician, revealed if he had signed an order for [REDACTED].#1 required close supervision with oral intake, he would expect staff to provide the supervision needed. Interview on [DATE] at 5:00 PM, and [DATE] at 12:00 PM, with the Administrator, revealed after the choking incident with Resident #1, administrative staff realized they needed to have a system in place to ensure Speech Therapy recommendations were communicated to nursing and to ensure the Care Plans were revised related to Speech Therapy recommendations. Continued interview revealed it was her expectation for the therapy department to communicate therapy recommendations verbally with the nursing staff and write the physician's orders [REDACTED]. She further stated she expected the MDS Coordinators to revise the Care Plans related to ST recommendations. Further interview revealed she expected staff to follow the facility's policy for developing and revising the care plans in order to ensure residents receive the care and services needed. The facility provided an acceptable credible Allegation of Compliance (A(NAME)) on [DATE], that alleged removal of the Immediate Jeopardy effective [DATE]. Review of the A(NAME) revealed the facility implemented the following: 1. Resident #1 expired on [DATE]. 2. On [DATE], the Vice President of Operations (VPO) was notified of the Immediate Jeopardy by the Administrator and initiated an action plan. On [DATE], the VPO conducted an audit of all residents who were ambulatory and checked to see if these ambulatory residents required a Mechanically Altered Diet; had food seeking behaviors; or required close supervision per Speech Therapy (ST) recommendations. No residents were identified as meeting this criteria. 3. On [DATE], the VPO conducted an audit of Comprehensive Care Plans for all residents who had received Speech Therapy (ST) services in the last three (3) months to identify any supervision recommendations by the Speech Therapist. Updates to supervision in care plans, if needed, were made by the DON on [DATE]. 4. On [DATE], the VPO revised the Speech Therapy Recommendation Communication Policy. 5. On [DATE] and [DATE], the VPO educated the Administrator, DON, ADON, and the Rehabilitation Director (RD) on the new Speech Therapy Recommendation Communication Policy. Competency was established through a post-test. 6. On [DATE], the Rehabilitation Director provided education to the Speech Therapist (ST) related to the Speech Therapy Recommendation Communication Policy and competency was established through a post-test. 7. On [DATE], the DON educated the shift supervisors on the new Speech Therapy Recommendation Communication Policy and competency was established through a post-test. 8. On [DATE], the DON, ADON, or the shift supervisors started education with the MDS Coordinators, and charge nurses (RNs and LPNs) on the new Speech Therapy and Communication Policy, and the education continued until all nurses had received the education. Competency was established through a post-test. 9. On [DATE], the VPO developed an audit tool to ensure compliance with the ST Recommendation Communication Policy. The audit tool will be utilized to review all ST recommendations, follow up for physician's orders [REDACTED]. This audit tool was initiated and utilized on [DATE], by the DON and ADON for all residents receiving a written ST recommendation after the audit on [DATE]. The DON will utilize the audit tool weekly for every Speech Therapy Recommendation for the next three (3) months and quarterly after that for 20% (twenty percent) of residents with recommendations. 10. On [DATE], the Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policies were revised by the VP of Operations. 11. On [DATE], the VPO educated the Administrator and DON on the new Snack Pass, Storage of Food and Fluids on the Medication Carts, and Meal Tray Cart Security Policy revisions and competency was established through a post-test. 12. On [DATE], all Department Heads including: Environmental Services, Activities Director, Social Service Director, Maintenance Director, Dietary Manager, Human Resource Manager, Business Office Manager, Administrative Assistant, Medical Records Manager, and the Infection Control Nurse, were educated on the new Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policy revisions and competency was established through a post-test. 13. On [DATE], all dietary staff and nursing staff (ADON, Unit Coordinators, MDS Coordinators, Hospitality Aides, SRNAs, LPNs, RNs) were educated on the new Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policy revisions by the Administrator and DON, and competency was established through a post-test. 14. From [DATE] through [DATE], remaining dietary staff and nursing staff were educated on the new Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policy revisions by the Department Heads, and competency was established through a post-test. No dietary or nursing employee will work without receiving the education and and proving competency. 15. On [DATE], the VPO developed an audit tool to ensure compliance with the new Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policies. 16. On [DATE], the audit tool was initiated and will be completed daily per a schedule by the Administrator, DON, ADON, Unit Coordinators, Shift Supervisors, or a Department Head for the on- site supervision of every snack pass, meal pass, and medication carts for the next two (2) weeks, then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly as part of the Continuous Quality Improvement (CQI) program to ensure compliance with the security of the meal tray carts, snack carts, medication carts. 17. On [DATE], the new ST Recommendations Communication, Snack Pass, Storage of Food and Fluids on the Medication Carts and Meal Tray Cart Security Policies were added to the New Hire Orientation Packet. The facility does not utilize agency for nursing services. 18. On [DATE], all snack carts were removed from service by the Maintenance Director. 19. On [DATE], the medication carts were cleared of all food and fluids and secured within the medication carts by the DON, ADON, and Unit Coordinators. 20. On [DATE], bedtime snacks were packaged individually and were passed individually by the SRNAs. 21. On [DATE], new snack coolers with locks were purchased by the Maintenance Director. 22. On [DATE], open meal tray carts were removed from service and new enclosed meal tray carts with locks were purchased by Maintenance Director. 23. On [DATE], the Quality Assurance Performance Improvement (QAPI) Committee met with the attendance of the VPO, Administrator, DON, Dietary Manager (DM) the Rehabilitation Coordinator (RC), and the Medical Director (MD) by phone. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. On [DATE], Resident #1 observed by a nurse to have a sandwich in his/her hand which was not consistent with the resident's Pureed diet. Upon further inspection of the sandwich, the nurse noticed a bite missing from the sandwich, and the nurse checked the resident's oral cavity and did not see any food. Afterward, Resident #1 was observed by staff to be choking, and after several unsuccessful [MEDICATION NAME] Maneuver attempts, Resident #1 expired. 2. Interview on [DATE] at 11:15 AM, with the VPO, validated she was notified of the Immediate Jeopardy on [DATE], by the Administrator and upon notification implemented an action plan. She stated she conducted an audit of all resident s who were ambulatory, and then checked to see if these ambulatory residents required a Mechanically Altered Diet; had food seeking behaviors; or required close supervision per Speech Therapy (ST) recommendations. She stated there were no residents who fit this criteria. Review of the Audit dated [DATE], revealed the VPO had conducted an audit to identify residents who were ambulatory and checked if these residents required: Mechanically Altered Diet; had food seeking behaviors; or required close supervision per ST recommendations; and no residents were identified. Review of the Resident Responses Analyzer Report, da(TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy and procedures it was determined the facility failed to have an effective system to ensure each resident's environment remained as free from accident hazards as possible, and each resident received adequate supervision to prevent avoidable accidents for one (1) of eight (8) sampled Residents (Resident #1). On [DATE], Resident #1 was observed by a nurse, coughing and choking on thin liquids during medication administration and physician's orders [REDACTED]. On [DATE], Speech Therapy was discontinued and the Speech Therapist's recommendations revealed Resident #1 was safe with Pureed Diet, but required close supervision with oral intake. However, physician's orders [REDACTED]. In addition, the Comprehensive Care Plan was not revised to reflect the need for close supervision with oral intake. On [DATE], at approximately 3:30 PM, Resident #1 was in the day area, near the East Hall Nurse's Station, when he/she was observed by a nurse to have a sandwich in his/her hand. Upon further inspection of the sandwich, the nurse noticed a bite missing from the sandwich. The nurse removed the sandwich from Resident #1's hand and assisted the resident to a chair. Afterward, Resident #1 was observed by staff to be choking, and after several unsuccessful Heimlich Maneuver attempts, the resident expired on [DATE] at 3:48 PM. The facility's failure to have an effective system to provide supervision and monitoring to prevent accidents and to maintain a safe environment has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (A(NAME)) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency verified the Immediate Jeopardy was removed on [DATE], as alleged, with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-323 at a Scope and Severity (S/S) of a D while the facility develops and implements the Plan of Correction (P(NAME)) and the facility's Quality Assurance monitors the effectiveness of the systemic changes to maintain an environment as free of hazards as possible and to ensure adequate supervision to prevent accidents. The findings include: Review of the facility's Safety and Supervision of Residents Policy, revised [DATE], revealed the facility would strive to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility wide priorities. Continued review of the Policy, revealed employees would be trained and in-serviced on potential accident hazards, how to identify and report accident hazards, and try to prevent avoidable accidents. Further review of the Policy, revealed the facility's resident oriented approach to safety addressed safety and accident hazards for individual residents. Per review of the Policy, staff should use various sources to identify risk factors for residents, including information obtained from the medical record history, physical exam, observation of the resident, and the Minimum Data Set (MDS) Assessment. Additional review of the Policy, revealed resident supervision was the core component of the system approach to safety, and the type and frequency of resident supervision would be determined by the individual resident's needs and identified hazards in the environment. Review of the facility's Therapeutic Diet Policy, revised [DATE], revealed therapeutic diets would be prescribed by the Attending Physician. Mechanically altered diets, as well as diets modified for medical or nutritional needs would be considered therapeutic diets. Continued review of the Policy, revealed the Clinical Dietician, nursing staff, and attending Physician would review, along with other orders, the need for, and resident acceptance of, prescribed therapeutic diets. The Clinical Dietician and nursing staff would document significant information relating to a resident's response to his/her therapeutic diet in the resident's medical record. Further review revealed any snacks provided must be compatible with the therapeutic diet. Review of Resident #1's clinical record, revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review of the MDS, revealed the facility assessed Resident #1's eating performance as independent with support of set-up help only. Further review of the MDS, revealed the facility assessed the resident as receiving a mechanically altered diet (specifically prepared to alter the consistency of food in order to facilitate oral intake) and as receiving a therapeutic diet. Review of Resident #1's Nurse's Note, dated [DATE] at 2:00 AM, revealed the resident was receiving a new diet of Nectar Thick Liquids due to having a coughing episode due to thin water. Per the Note, the resident coughed so hard the resident's face and neck turned red. Review of the physician's orders [REDACTED]. Review of the Speech Therapy Referral Request, dated [DATE], revealed Resident #1 was observed coughing/choking on thin liquids during medication pass. Further review revealed the resident's diet was downgraded to Nectar Thick Liquids pending evaluation. Review of the Speech Therapy (ST) Evaluation, dated [DATE], revealed the reason for the ST referral was a recent episode of coughing and choking on thin liquids requiring skilled intervention to determine safest, least restrictive diet level. Continued review revealed an analysis of behaviors impacting safety included: reduced attention to task; inattention to bolus; inattention to presentation; impulsive rate; unsafe intake amounts with decreased self-correction; poor self-monitoring skills; and decreased safety awareness. Further review revealed ST recommendation of close supervision for oral intake. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review of the MDS, revealed the facility assessed Resident #1's eating performance as independent with support of set-up help only. Further review of the MDS, revealed the facility assessed the resident as receiving a mechanically altered diet (requiring change in texture of food or liquids), and as receiving a therapeutic diet. Review of the Comprehensive Plan of Care, revised [DATE], revealed Resident #1 was at risk for complications and/or injury related to impulsive behaviors, agitation, and refusing medication. The goal stated the resident would have no injury and or complications related to behaviors. The interventions included: assess resident and try to find out circumstances behind behavior; and encourage diversional activities when resident having behaviors. A new intervention was added on [DATE], after the resident had the choking/coughing episode, which stated the resident had a diet and fluid change and to be observant of resident seeking out regular consistency food/fluids and offer appropriate consistency snacks. Review of Resident #1's Comprehensive Plan of Care, revised [DATE], revealed the resident was at nutritional risk related to receiving a mechanically altered pureed diet for a [DIAGNOSES REDACTED]. The goal stated the resident would have no significant weight loss and would tolerate diet through next review. There were several Care Plan interventions to include: change diet consistency to pureed; nosey cup ( adapted drinking cup with cut out for the nose) for all nectar thick liquids; provide, encourage, and assist as needed with diet and fluids; diet per Medical Doctor order; assist with meals according to daily care plan; and be alert for chewing and or swallowing precautions. Continued review revealed no documented evidence the Care Plan was revised to include the recommendations per ST on [DATE], for close supervision for oral intake. Review of the Speech Therapy Discharge Summary, dated [DATE], revealed Resident #1 was seen for Dysphagia Therapy and was safe with pureed foods, but required close supervision due to impulsive behaviors. The section under Patient and Caregiver Training, revealed the resident was unable to cognitively carry over skilled safety precautions and would remain on Nectar Thick Liquids. Per the Summary, this and safety precautions relayed to staff. The section titled, Discharge Status and Recommendations, revealed recommendations for Puree consistency diet and Nectar Thick Liquids. Further review of the recommendations revealed the resident was safe with Pureed Diet and Nectar Thick Liquids with staff supervision, but required close supervision for oral intake. Review of Resident #1's Verbal physician's orders [REDACTED]. However, the recommendations for close supervision for oral intake per the Speech Therapy Discharge Summary, were not written into the orders. Further review of the current Comprehensive Care Plan, revised [DATE], revealed there was no documented evidence the Care Plan was revised after the ST Discharge Summary, dated [DATE], with recommendations per ST, for close supervision for oral intake. Review of the State Registered Nurse Aide (SRNA) [DATE] Daily Care Plan Record, revealed under the Diet Section, interventions for: set-up help only; dining room for breakfast, lunch and dinner; assistive device of scoop plate and nosey cup; Nectar Thick Fluids; no water pitcher; and no straw. However, there was no documented evidence the resident was on swallowing precautions or required close supervision with oral intake. Interview on [DATE] at 6:45 PM, with Speech Therapist (ST) #1, revealed Resident #1 required close supervision with the rate and amount of food intake because he/she could not judge a reasonable amount of food intake due to his/her impulsive behavior while eating. The ST stated the resident would often take large bites, was fast paced while eating, and did not chew the food adequately before swallowing, putting the resident at risk for choking. Further interview revealed the resident needed supervision and cueing while eating with instructions to slow down, take smaller bites, and to chew adequately. She further stated the resident would do very well when cued and supervised. Review of the facility's Five (5) day Follow up and Investigation Report, dated [DATE], revealed on [DATE] at approximately 3:25 PM, Resident #1 was seen with a sandwich. According to the Report, the nurse immediately intervened, removed the sandwich, and visually checked the resident's oral cavity with no food particles seen. Per the Report the resident was in no distress. Further review of the Report, revealed the nurse assisted the resident to sit down and turned to get the resident a different snack when the resident stood up. Resident #1's knees started to buckle when another nurse who was present in the day area assisted the resident to the floor. According to the Report, the other nurse thought the resident was having a seizure as the resident had a history of [REDACTED]. Resident #1 was unresponsive and skin was cyanotic (bluish color due to lack of oxygen in the blood). Abdominal thrusts were initiated and 911 was called. Continued review of the Report, revealed abdominal thrusts, oral suction, and oxygen therapy continued until Emergency Medical Services (EMS) arrived. Per the Report, when EMS arrived, they verified Do Not Resuscitate (DNR) code status, and verified absence of a pulse and respirations and the resident was pronounced dead. Review of the Nurse's Note, dated [DATE] at 4:15 PM, completed by Licensed Practical Nurse (LPN) #4, revealed upon return to the nurse's station, she observed Resident #1 standing in the middle of the hall with a sandwich in his/her hand. Per the Note, LPN #4 confiscated the sandwich and upon further inspection, noticed a bite missing from the sandwich and assessed the resident's mouth for any food particles, and none were noted. Further review of the Note, revealed Resident #1 appeared to be without signs and symptoms of respiratory distress and LPN #4 redirected the resident to a chair in the day area and assisted the resident to a seated position. Per the Note, LPN #4 had her back to the resident and when she turned around she observed LPN #3 and a State Registered Nurse Aide (SRNA #6) attempting to prevent Resident #1 from falling forward. Per the Note, LPN #4 assisted the staff with getting the resident back into the chair. Further review of the Note, revealed LPN #3 stated the resident was turning purple, and two (2) staff members stayed with the resident at the chair while LPN #3 verified the resident's code status as Do Not Resuscitate (DNR). Continued review of the Note, revealed 911 was called at 3:36 PM and the resident was assisted to the floor in a lying position. Per the Note, the resident's body was noted to be very rigid and the resident's tongue was very thick. Abdominal thrusts, mouth sweeps, suction, and oxygen therapy were provided. Further review of the Note, revealed staff provided several repeated rounds of abdominal thrusts and mouth sweeps until EMS arrived and attached electrodes and a portable heart monitor to the resident. After EMS placed the resident on the monitor, the resident was noted to have asystole (absence of a heart beat). Per the Note, EMS notified the Coroner and remained with the body until the Coroner arrived. Review of the EMS Patient Care Record, dated [DATE], revealed EMS received the call at 3:36 PM for a possible Cerebrovascular Accident (CVA) or choking patient. Per the Record, EMS was at the patient's side at 3:48 PM. Further review of the Report, revealed the patient was found lying supine (on back), on the floor, unresponsive, pulseless and apneic (not breathing) with cyanosis of the face and lips. Per the Record, patient's pupils were fixed and dilated; patient was in asystole; and there was nothing visible in the airway. Continued review of the EMS Patient Care Record, revealed the patient was in the care of nursing home staff, who advised EMS two (2) minutes prior to call they attempted Heimlich Maneuver and suctioned patient without success, but did manage to sweep small amounts of turkey and bread from the patient's mouth. Per the Record, staff advised they did not administer Cardiopulmonary Resuscitation (CPR) due to the patient's (Do Not Resuscitate) DNR order and staff provided an original valid EMS DNR order notarized with appropriate signatures. According to the Record, the patient was pronounced dead at 3:48 PM, and the Coroner was notified. Further review of the Record, revealed staff advised patient was recently placed on a food restriction due to choking hazard and was non-compliant, often stealing other patient's food or stealing from the food cart. Per the Record, one staff member advised she saw the patient with a sandwich in hand minutes before the incident and was unable to visualize food in the patient's airway at that time. Review of the Coroner's Report, dated [DATE], revealed Resident #1 was pronounced dead on [DATE], with immediate cause of resulting death as obstruction of airway, with choking listed as a sequential condition leading to the cause death. Interview, on [DATE] at 9:18 AM, with LPN #4 who worked the 7:00 AM to 7:00 PM shift on the East Unit where Resident #1 resided on the day of the incident, revealed she was clocking back in from lunch when she saw Resident #1 standing in the middle of the hall with a sandwich in hand. She stated when she took the sandwich away from the resident, she noticed a bite missing from the sandwich. LPN #4 stated she assisted Resident #1 to a nearby chair, checked the resident's mouth for food, and when she did not see any, she turned around to get the resident an appropriate snack. LPN #4 further stated her back was to the resident, and she heard a commotion behind her. Per interview, when she turned around she saw LPN #3 and SRNA #6 attempting to assist the resident because it looked like the resident was going to fall. Further interview with LPN #4, revealed LPN #3 and SRNA #6 assisted the resident to the chair, and LPN #3 yelled out that the resident was purple. Per interview, LPN #4 ran over, helped lower the resident to the floor, and began the Heimlich Maneuver while LPN #3 yelled out to call 911 and ran to the desk to check the resident's code status. LPN #4 stated, staff hooked the resident up to oxygen, and tried to suction the resident's mouth and got out what looked like part of a turkey sandwich. Per interview, staff kept doing the Heimlich Maneuver and sweeping the resident's mouth for food until the ambulance and fire department arrived. LPN #4 further stated when EMS placed the electrodes and turned on the heart monitor they said the resident was in asystole and then pronounced the resident dead. Continued interview with LPN #4 revealed the dietary department had delivered the snack cart to the unit while she was at lunch and placed it behind the nurse's station. Per interview, Resident #1 probably got the sandwich from the snack cart because the resident had a history of [REDACTED]. Further interview revealed the snack cart should not have been left unsupervised or unattended because residents could take food or snacks that could harm them. Interview on [DATE] at 2:25 PM, with LPN #3, who typically worked the 7:00 AM - 3:00 PM shift on the West Hall, revealed dietary staff delivered the snack carts to the nurse's station, and would place the cart either inside the nurse's station or beside the nurse's station. She stated the aides would then pass out the snacks to the residents. LPN #3 stated the snack carts were not to be left behind the nurse's station or unattended because a resident could get a snack that did not belong to them. Continued interview revealed on [DATE], the day of the incident, she was going to the East Hall to clock out when she stopped to assist SRNA #6 pull a resident up in a chair in the East Hall day area and noticed Resident #1 falling toward her. LPN #3 stated she and SRNA #6 grabbed Resident #1 and assisted the resident to a chair. Per interview, after assisting Resident #1 into the chair she noticed the resident was turning purple and gasping. LPN #3 stated she told SRNA #6 the resident was choking and yelled out to call 911. Per interview LPN #2 came to assist SRNA #6 in lowering the resident to the floor while she (LPN #3) went to the desk to check the resident's code status. Further interview with LPN #3, revealed after checking Resident #1's medical record, she noted the resident had a DNR code status and immediately ran back to the resident and gave three (3) abdominal thrusts while LPN #2 swept the resident's mouth and removed some food that looked like half of a chewed up sandwich. LPN #3 stated the resident took several breaths and started struggling to breath and she (LPN #3) continued abdominal thrusts while LPN #2 continued sweeping the resident's mouth for food. Per interview, SRNA #6 and other staff obtained oxygen and a suction machine. LPN #3 further stated she suctioned more food out of the resident's mouth, but the resident was still struggling to breath so they continued repeating abdominal thrusts and mouth sweeps until EMS and the firefighters arrived and put electrodes on the resident and placed the portable heart monitor. Continued interview with LPN #3, revealed at that time, EMS stated the resident was in asystole and pronounced the resident dead. Additional interview with LPN #3, revealed she did not know where Resident #1 got the sandwich because she was working the West Hall. However, she stated Resident #1 had a history of [REDACTED]. Per interview, Resident #1 had a history of [REDACTED]. LPN #3 stated all staff were required to supervise the residents. She further stated the nurses were required to do rounds every two (2) hours opposite the aides doing rounds every two (2) hours to lay eyes on residents. Interview on [DATE] at 11:05 AM, with LPN #2, who typically worked the 7:00 AM to 3:00 PM on the East Hall, revealed Resident #1 wandered everywhere and would go behind the nurse's station if staff were back there. LPN #2 stated staff had to hide water pitchers due to the resident taking them off the medication carts and the resident would take food from anywhere. LPN #2 further stated she had to take food away from Resident #1 several times because the food was not the correct diet or consistency. Continued interview revealed she was sure there were times the snack cart was left behind the nurse's station unsupervised. Further interview revealed LPN #2 stated she was working the day Resident #1 choked and died . She stated she was heading to clock out when she stopped to assist SRNA #6 pull another resident up in a chair and noticed Resident #1 looked like he/she was falling. She further stated, when she and other staff realized the resident was choking, they assisted the resident to the floor and performed abdominal thrusts until the ambulance arrived. LPN #2 stated she swept the resident's mouth and got part of a sandwich out of the resident's mouth. LPN #2 further stated LPN #4 held up a sandwich and stated the resident had taken a bite out of it. Interview on [DATE] at 8:15 PM, with SRNA #6, who typically worked weekends from 7:00 AM to 7:00 PM on the East Hall, revealed dietary staff would just drop the snack carts off outside the nurse's station and when staff noticed the carts were there, they would pass out snacks to their assigned residents. SRNA #6 stated when the carts were left unattended residents and visitors would just help themselves to the snacks, even if it wasn't their snack. SRNA #6 stated Resident #1 was always walking up and down the halls with his/her walker and if he/she saw any food or drinks anywhere, he/she would just grab it and say mine, mine. SRNA #6 further stated Resident #1 would take food and drinks away from other residents. Continued interview with SRNA #6, revealed Resident #1 sat at the early feeder table during meals and was to be fed or watched when he/she ate because the resident would eat too fast and could choke. SRNA #6 stated on [DATE], the day of the incident, she was working the 7:00 AM to 7:00 PM shift on the East Hall when she and LPN #3 saw Resident #1 jump up out of the chair and it looked like he/she was going to fall. Per interview, she and LPN #3 ran over to the resident and helped the resident to sit down. SRNA #6 stated that's when they noticed the resident was purple and blue and one of the nurse's yelled out that the resident was choking. Per interview, they then positioned the resident on the floor and started patting the resident's back and checking his/her mouth. SRNA #6 stated at first they thought the resident was having a seizure until they saw the food in the resident's mouth. SRNA #6 further revealed, LPN #4 told staff Resident #1 had taken a sandwich off the snack cart, and when LPN #4 took the sandwich away from the resident, LPN #4 noticed a bite had been taken out of the sandwich. Further interview with SRNA #6, revealed when the snack cart was delivered, the staff just passed out the snacks, and didn't sit with the residents while they ate the snacks. Interview on [DATE] at 4:10 PM, with the Dietary Aide who delivered the snack cart to the units at approximately 3:00 PM on [DATE], the day of the incident, revealed she delivered the snack carts to the units and asked whoever she saw if it was okay to leave the carts behind the nurse's station, and then she returned to the kitchen. She stated she did not know if the snack cart was left unattended after she dropped it off on [DATE] on the East Unit, and did not remember who she had asked about leaving the snack cart at the nurse's station that day. She stated she had seen snack carts sitting outside the nurse's station unattended, after snacks were passed, with trash and sometimes unopened snacks on the cart. Interview on [DATE] at 10:20 AM, with SRNA #3, who typically worked 7:00 AM to 3:00 PM on the West Hall, revealed the dietary aides would deliver the snack carts and just leave them behind the nurse's station. Per interview, when staff on the unit saw the carts, they were to start passing out the food. Continued interview revealed the dietary aides would let someone know the carts were there, but that did not mean someone was there watching the carts until the snacks were passed to the residents. Observation on [DATE] at 3:35 PM, revealed the Assistant Director of Nursing (ADON) brought the snack cart to the West Unit and handed it off to SRNA #7 and SRNA #8. Both SRNA's took the snack cart and began passing snacks to residents on the West Hall. Continued observation at 3:37 PM, revealed SRNA #7 and SRNA #8 took snacks off the cart, left the cart in the middle of the hall, and entered two (2) separate resident rooms, leaving the snack cart unsupervised and unattended by a staff member. Further observation at 3:37 PM, revealed a visitor exited another resident's room, walked up to the snack cart, took a snack off the unsupervised cart, and re-entered the resident's room without SRNA #7's and SRNA #8's knowledge. Interview on [DATE] at 3:45 PM, with SRNA #7, who had received the snack cart from the ADON at 3:35 PM, revealed the snack cart should not have been left unattended by staff in the middle of the hall because it was unsafe for residents. Continued interview revealed visitors should not be helping themselves to snacks on the carts because they might take something that the resident should not have. Interview on [DATE] at 3:46 PM, with SRNA #8, who had received the snack cart form the ADON at 3:35 PM, revealed the snack cart should never be left unattended by staff because a resident might take something that was not on their diet and they could choke on food they shouldn't have. Continued interview revealed visitors should not take snacks off the carts for residents because they could give a resident a snack which the resident was not supposed to have. Interview on [DATE] at 4:40 PM, with the Director of Food and Nutrition Services, revealed the snack carts were delivered to the units by the dietary staff three (3) times a day, and the carts should not be left unattended by facility staff because there were residents who were mobile in the facility who might have dietary restrictions and they could be at risk for harm if the carts were left unsupervised. Interview on [DATE] at 3:15 PM with the ADON, revealed dietary staff was responsible for delivering the snack carts to the units and the carts were to be supervised which started after [DATE], due to Resident #1's choking incident. She stated SRNA #7 and SRNA #8 should have ensured the snack cart was supervised on [DATE], when she brought the cart up to the unit. The ADON stated she preferred staff worked with a partner so one (1) staff member could stay with the cart while another staff member took the snack into the resident's room. She further stated staff should not leave the cart in the hall unattended because someone could take a snack off the cart that was not appropriate for their diet. Per interview, a resident could choke on food anytime food was accessible and unattended. Interview on [DATE] at 4:22 PM, with the Director of Nursing (DON), revealed she expected staff to maintain a safe environment to protect residents from potential harm. She stated the snack cart should never have been left unattended on [DATE], where a resident or a visitor could take snacks from the cart because a resident could consume food that could potentially harm them, or a visitor could unknowingly give a resident food which could harm them. The DON further stated if Resident #1 required close supervision with oral intake, the resident should not have had access to food unsupervised. Per interview, if a resident required close supervision with oral intake, staff should provide the supervision needed, and if a resident required supervision during meals, she also expected staff to be observant and supervise those residents during snack consumption as well. Interview on [DATE] at 1:50 PM with the Attending Physician, revealed if he had signed an order for [REDACTED]. He further stated if Resident #1 required close supervision with oral intake, he would expect staff to provide the supervision needed. Interview on [DATE] at 5:00 PM, and [DATE] at 12:00 PM, with the Administrator, revealed she expected staff to follow the facility's policy and maintain a safe environment for residents. Continued interview revealed she expected staff to supervise residents to protect them from potential harm depending on the type of supervision each resident needed. She stated residents who were at risk for choking or needed close supervision with oral intake should be supervised during meals and snacks to prevent the possibility of choking. Further interview with the Administrator, revealed she felt Resident #1 had been supervised with meals and snacks, but due to the resident's impulsive behaviors, it was difficult to keep food and drink items out of Resident #1's reach at all times. Per interview, after the choking incident with Resident #1, administrative staff realized they needed to have a system in place to ensure residents were safe and to prevent them from obtaining foods or fluids which could pose a choking hazard; ensure Speech Therapy recommendations were communicated to nursing and followed; and, ensure Care Plans were revised to reflect individual needs related to supervision of food and fluids. The facility provided an acceptable credible Allegation of Compliance (A(NAME)) on [DATE], that alleged removal of the Immediate Jeopardy effective [DATE]. Review of the A(NAME) revealed the facility implemented the following: 1. Resident #1 expired on [DATE]. 2. On [DATE], the Vice President of Operations (VPO) was notified of the Immediate Jeopardy by the Administrator and initiated an action plan. On [DATE], the VPO conducted an audit of all residents who were ambulatory and checked to see if these ambulatory residents required a Mechanically Altered Diet; had food seeking behaviors; or required close supervision per Speech Therapy (ST) recommendations. No residents were identified as meeting this criteria. 3. On [DATE], the VPO conducted an audit of Comprehensive Care Plans for all residents who had received Speech Therapy (ST) services in the last three (3) months to identify any supervision recommendations by the Speech Therapist. Updates to supervision in care plans, if needed, were made by the DON on [DATE]. 4. On [DATE], the VPO(TRUNCATED)

Based on interview, record review, review of the facility's policy and review of the Kentucky Revised Statutes (KRS), it was determined the facility failed to have an effective system to ensure allegations of abuse were reported immediately to the Administrator and to the appropriate State Agencies per policy and state law and fully investigated for three (3) of twenty-one (21) sampled residents (Residents #1, #12 and #15). In addition, the facility failed to protect residents in order to prevent further potential abuse while the investigation was in progress. State Registered Nursing Assistant (SRNA) #2 witnessed alleged incidents of verbal abuse for Resident #13 and #15; and an alleged incident of physical abuse of Resident #1 on the evening shift of 02/20/14. However, she did not report the alleged abuse until 02/25/14, five (5) days later. On 02/25/14, she reported the alleged abuse to Registered Nurse (RN) #1 who recognized the allegations as abuse and immediately had SRNA #2 notify the Director of Nursing (DON) via phone. Although the DON notified the Administrator the evening of 02/25/14 of the alleged abuse, there was no documented evidence the facility began an investigation until 02/27/14, two (2) days after having been notified of the allegations. The facility performed an investigation which initially only consisted of interviewing Resident #12, Resident #15 and Resident #1's roommate on 02/27/14. The facility's investigation failed to ensure other interviewable residents were interviewed as soon as possible after the allegations were received. The facility's investigation failed to ensure staff who had worked the evening of 02/20/14 were interviewed and written statements obtained and failed to ensure SRNA #1, the alleged perpetrator was interviewed timely and her written statement obtained. The facility's investigation failed to ensure Resident #1, who had been allegedly physically abused, received an assessment after the facility was notified. The facility's investigation also failed to ensure documented evidence SRNA #2 was re-educated on reporting abuse and SRNA #1 was re-educated regarding the facility's abuse policies. Additionally, as a result of the allegations not being reported immediately to the Administrator, SRNA #1, the alleged perpetrator was allowed to continue caring for residents on 02/20/14 and 02/21/14; therefore leaving residents unprotected from the potential for further abuse. The facility failed to ensure SRNA #1, the alleged perpetrator was removed from resident care after the facility received the allegations on 02/25/14 and the SRNA therefore reported to work on 02/26/14 and cared for residents for approximately thirty (30) minutes before being suspended. Although the facility's administration became aware of the allegations on 02/25/14, the facility failed to ensure State Agencies were notified of the verbal abuse allegations until 02/28/14; and failed to ensure the physical abuse allegation was reported to the State Agencies until 03/05/14. (Refer to F-225, F-226, F-490, and F-520). Based on the above findings, it was determined the facility's failure to protect and comprehensively investigate alleged incidents of verbal and physical abuse; and to immediately report incidents of alleged abuse to the State Agencies, was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 03/05/14 and were determined to exist on 02/20/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/12/14 with the facility alleging removal of the Immediate Jeopardy on 03/07/14. The Immediate Jeopardy was verified to be removed on 03/07/14 prior to exiting the facility on 03/13/14, with remaining non-compliance at CFR 483.13, Resident Behavior and Facility Practice, F-225 Abuse, with a Scope and Severity of "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure all allegations were immediately reported to facility administration and State Agencies and all allegations of abuse were thoroughly investigated. The findings include: Review of the KRS Chapter 209.030 revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of the facility's policy titled, "Policy on Abuse", undated, revealed all staff was required to report any observation or suspicion related to possible abuse to their supervisor, Social Services (SS), DON and Administrator immediately. The policy stated the facility would immediately investigate the alleged incident during the shift on which the alleged abuse occurred including interviews with the resident or other resident witnesses. Policy review revealed the Administrator, DON and SS Director were to conduct the investigations of abuse allegations when identified; and to protect residents from harm during an abuse investigation. Review of the policy revealed when a staff member was implicated in a potential resident abuse situation, the staff member was to have been removed from all resident care areas and sent home after a written statement had been obtained from them. The policy indicated the investigation was to have included interviews with the staff member implicated, and the staff member was to make a written statement of their knowledge/version of the incident. Additionally the policy revealed interviews were to have been completed with all staff on that unit to make sure all information was gathered promptly and documented. Continued review revealed allegations were to be reported to the appropriate State Agencies; and the Administrator would be responsible for ensuring the facility's compliance with all abuse and neglect provisions. Review of the Employee Handbook, undated revealed all suspected or alleged incidents of abuse, neglect or exploitation were to be reported immediately to the employee's supervisor and the nurse on duty. According to the Handbook, if an employee was involved, he/she might be restricted from further contact with residents during the investigation process and the employee's written statement would be obtained. Review of the facility's investigation, "Combined Incident Report/Final Report" form submitted to State Agencies on 02/28/14, revealed SRNA #2 had been working with SRNA #1 and felt her conversation with Resident #12 and Resident #15 had been inappropriate and "too familiar". Review of the form revealed the "incident date" had been noted as 02/26/14; and the shift had been over when this information was reported to the House Supervisor. Continued review of the form revealed the House Supervisor had reported the information to the Administrator; and SRNA #1 had been immediately suspended to protect the residents. Per the form, the DON and the Social Worker (SW) interviewed two (2) residents, Resident #12 and #15 on 02/27/14, and they had no complaints of staff members saying or doing anything to them which they had felt was inappropriate. Review of the form revealed other residents had not been interviewed until 03/03/14. The form indicated the facility's conclusion had been to return SRNA #1 to work on the day shift and on another unit to monitor her closely, and to offer training in proper technique by the Staff Development Director. Further review of the form revealed no documented evidence of the physical abuse allegation involving Resident #1; or documented evidence other staff members were interviewed. Additionally, review of the form revealed no documented evidence of who initiated the investigation; or the dates and times the investigation was started and review of the form revealed it indicated the State Agencies were notified when the Administrator and DON were notified. On 03/05/14 at 10:30 AM, a copy of SRNA #2's written statement was received which indicated the alleged physical abuse regarding Resident #1. Review of the "Resident Abuse Policy Acknowledgement" form dated and signed by SRNA #1 on 01/20/14, and by SRNA #2 on 02/11/14, revealed it was the policy of the facility that any type of abuse would be reported immediately to protect residents from physical, sexual, emotional or mental abuse. The form indicated the procedure included reporting any suspected abuse immediately to the Administrator/designee, DON and Social Worker (SW). Further review of the Acknowledgement form revealed if abuse of any type was witnessed and the employee did not report immediately they would receive disciplinary action up to and/or including termination. Review of SRNA #2's written statement, undated, received from the DON on 03/5/14 at 10:30 AM, revealed SRNA #2 worked with SRNA #1 on 02/20/14 and had observed SRNA #1 tell Resident #15 she was not not going to keep putting him/her on the bedpan as she did not have time to fool with his/her "stinking ass". Continued review of the statement revealed that same evening, SRNA #1 told Resident #12 to open his/her legs so she could "clean out" her "coochie." Further review of the statement revealed SRNA #2 observed SRNA #1 being "very rough, practically slamming" Resident #1 in the chair; and the resident "cried out very loud, as if in pain." In addition, review of the statement revealed SRNA #2 had requested not to work with SRNA #1 again. Interview with State Registered Nursing Assistant (SRNA) #2 on 03/05/14 at 3:30 PM and on 03/14/14 at 1:23 PM, revealed she had received training related to abuse; and knew if she were to witness abuse, she would need to report it immediately to the Charge Nurse or DON after ensuring the resident's safety. SRNA #2 stated she was unsure of the date and time of when she witnessed SRNA #1 being abusive towards Resident #15, Resident #12 and Resident #1. She indicated she knew it had been sometime "after dinner". SRNA #2 stated SRNA #1 had told Resident #15 she did not have time to "fool" with him/her taking his/her "stinking ass off the bed pan all the time". According to SRNA #2, that same evening, she and SRNA #1 were providing care for Resident #12; and SRNA #1 told Resident #12 "to open" his/her legs, so she could clean her "coochie". She stated she felt like these comments had been a fine line between "inappropriate or abuse". She indicated she had gone into Resident #1's room that same evening and SRNA #1 had been transferring the resident by herself by picking the resident up under his/her arms, was "rough" with him/her and slammed the resident down. She stated, she had heard Resident #1 make a noise that startled her, like maybe the resident was uncomfortable or in pain. SRNA #2 stated she had felt like SRNA # 1 had been rough and abusive with Resident #1. She stated Resident #1 had no "visible injury"; and she had not reported what she had witnessed until 02/25/14 when she told Registered Nurse (RN) #1. Further interview revealed RN #1 had told her what she had witnessed was abuse and it needed to be reported immediately. SRNA #2 stated RN #1 called the DON and had her tell the DON what she had witnessed. She stated the DON told her she would talk to her more about what she had witnessed when she (DON) returned to work. SRNA #2 stated the next day RN #1 asked her to write down what happened on a piece of paper and she had done that. She stated the Administrator had talked to her about what she had witnessed also; however she could not recall the date and time. SRNA #2 stated the Administrator had told her he would do an investigation; and had called her at home on 03/03/14 and notified her she had been suspended. SRNA #2 stated she did not want to work with SRNA #1 anymore; as she was aggressive, abrasive and some of her conversations were not appropriate. Interview with SRNA #1 (perpetrator) on 03/05/14 at 1:50 PM and 03/14/14 at 10:34 AM, revealed she had received training on abuse and was aware transferring residents roughly and telling a resident you did not have time to fool with their "stinking ass" would be considered abuse. She stated she knew staff should use the appropriate term for private parts also. SRNA #1 stated, the Administrator had called her into his office on 02/26/14, "while I was out on the floor taking care of my" residents and told her she "needed to go home for talking badly to a resident". According to SRNA #1, the Administrator had not discussed the allegations; and told her the DON would investigate and get back with her. SRNA #1 stated she had asked which residents he had been referring to and who had reported her and the Administrator told her it was confidential. SRNA #1 stated she called the DON on 02/27/14 and asked her what she had been accused of; and the DON said she was investigating, had a few more people to talk to, and would get back in touch with her after that. Continued interview revealed SRNA #1 had not been asked to write a statement related to the allegation of abuse incidents. She stated "I do not recall the DON asking me about my side of the story." SRNA #1 indicated she had talked to the DON again on 03/01/14, who told her they had completed the investigation and determined the allegations not to be true. She stated the DON told her she could come back to work on 03/02/14. SRNA #1 stated she had "never got a chance to talk to" the DON who had indicated to her she would go over the "paperwork" regarding the allegations with her. Record review of SRNA #1 (perpetrator) time card revealed on 02/20/14 she worked from 3:00 PM to 11:15 PM, on 02/21/14 worked from 4:15 PM to 11:15 PM and on 02/26/14 worked from 3:00 PM to 3:30 PM. Interview with SRNA #5 on 03/05/14 at 3:11 PM revealed she had been working on the evening of the alleged abuse; however no one had interviewed her. Interview with Licensed Practical Nurse (LPN) #4 on 03/05/14 at 6:27 PM, revealed she had worked the evening of 02/20/14, and had not been interviewed by facility staff related to any abuse incident. Interview with LPN #5 on 03/05/14 at 2:43 PM, revealed she had worked on evening shift on 02/20/14, and the facility had never talked to her about any occurrence of allegations of abuse. Interview with RN #1, House Supervisor on 03/05/14 at 3:50 PM, on 03/08/14 at 3:15 PM and on 03/11/14 at 1:48 PM, revealed SRNA #2 reported to her about 10:30 PM on 02/25/14, she had witnessed SRNA #1 on 02/20/14 slam Resident #1 into the wheelchair. She stated SRNA #2 told her she had also witnessed SRNA #1 tell Resident #12 to spread her/his legs so she could clean her "coochie" and had observed SRNA #1 tell Resident #15 she was "tired" of putting her/his "stinky ass" on the bedpan. She stated she told SRNA #2 she should have reported the allegations immediately after her observations. RN #1 stated she called the DON and had SRNA #2 report her allegations to the DON at that time. RN #1 stated when she talked to the DON after SRNA #2 she asked the DON if she needed to do anything; and the DON told her she would take care of it and report it to the Administrator. According to RN #1, the DON told her she did not think she would report the allegations to "state", because it had happened a week ago; and SRNA #2 should have reported it then. RN #1 stated she had not performed a skin assessment on Resident #1 after receiving the allegation of physical abuse; however, in hindsight she should have. RN #1 stated she had not done "anything with" SRNA #1 that night because after getting off the phone with the DON it was "about 11:00 PM" and time for SRNA #1 to go home. Continued interview with RN #1 revealed on 02/26/14, she had been working and noted SRNA #1 was there caring for residents; she stated she went to the Administrator's office to report this as the DON had not been at the facility. She indicated the Administrator had been on the phone and told her he would get to her "when he was done". She stated she spoke with the Administrator at approximately 4:00 PM, indicating she had received report from both units before speaking to him. RN #1 stated she informed the Administrator SRNA #1 was working and should have been suspended immediately as allegations of abuse had been made against her. She stated the Administrator told her he was aware of the allegations and had RN #2, Unit Manager get SRNA #1, bring her to his office and suspended SRNA #1 at that time. Additionally, interview with RN #1 revealed the facility had not followed the policy as SRNA #1 was not suspended immediately pending the investigation. RN #1 stated no one from the facility had talked to her further regarding the allegations. The RN stated on 02/26/14 the DON had called her and told her she had learned from a conference she attended that the guidelines for abuse had changed; and for an incident now to be considered abuse, the facility had to prove malicious intent. She stated the DON had informed her on 02/27/14, the facility had interviewed the residents and were unable to "prove anything had happened". RN #1 further stated, she had thought about calling the State Agency to report the abuse; however on Friday, 02/28/14 the DON informed her she was "thinking" about reporting the incidents to the "state". Interview with RN # 2, Unit Manager on 03/05/14 at 10:20 AM, at 6:52 PM and on 03/08/14 at 2:30 PM, revealed RN # 1 had been mad on 02/26/14 when she saw SRNA #1 working and wanted to know why the SRNA was there. She stated RN #1 told her she was going to the Administrator's office and indicated shortly after that the Administrator called her and asked her to bring SRNA #1 to his office and she took the SRNA there. She indicated SRNA #1 was told there had been an allegation of abuse against her, and the facility's policy was to suspend her until the investigation had been completed. RN #2 stated the Administrator asked her to walk SRNA #1 to the time clock and out of the building. RN #2 stated SRNA #1 should not have worked on 02/26/14, after Administration had been made aware of the allegations and she felt the facility had not followed the abuse protocol. Interview with the SS Director on 03/5/14 at 2:50 PM, revealed transferring someone in a rough manner and inappropriate use of terminology were examples of abuse. She stated when an abuse allegation was reported the DON, Administrator and herself collaborated on the investigations with her usually interviewing residents and the DON interviewing staff. She stated the DON oversaw the investigations and the Administrator was to submit the initial investigation form to the State Agencies within twenty-four (24) hours; with the final report in five (5) days. She stated if an allegation of abuse was received regarding the care of a staff member she interviewed residents and they would need to talk to "several" staff on that shift. She stated the Administrator and DON told her who to interview; however do not tell her what to ask the residents. The SSD stated she had been notified of the allegations made by SRNA #2 on 02/26/14, when she and the DON were at a conference and she and the DON started talking to residents the next day. Continued interview revealed she had interviewed all interviewable residents on the hallway SRNA #1 had worked on; except Resident #15 who the DON had interviewed. The SS Director stated the facility should have initiated the investigation when they were notified of the allegations on 02/25/14; and SRNA #1, the alleged perpetrator should have been removed from the building the day of the allegation to keep residents safe pending the results of the investigation. She indicated the Administrator was to report allegations to the State Agencies when the facility became aware. The SS Director stated SRNA #2 should have reported the allegations on 02/20/14, when she had witnessed them. Interview with the DON on 03/05/14 at 10:30 AM, at 6:30 PM, on 03/11/14 at 3:00 PM, and on 03/13/14 at 1:53 PM, revealed after staff witnessed abuse they were to notify their supervisor immediately, and the Administrator was also to be notified immediately. She stated the supervisor starts the investigation; and the facility had twenty-four (24) hours to notify the State Agencies. The DON stated the final investigation report was due to State Agencies in five (5) days. The DON stated after the facility received an allegation of abuse the alleged perpetrator was not allowed to work; and was suspended until the investigation had been completed. She stated she was responsible for completing the "abuse packet"; and had not felt the facility waited too long to investigate the allegations received on 02/25/14 at 10:30 PM, as they were verbal abuse and not physical abuse. She stated when she talked to SRNA #2 on the phone, she told her SRNA #1 had been verbally abusive last week. The DON stated she told SRNA #2 she should have reported the abuse to her supervisor right away last week when it occurred. The DON stated SRNA #2 had informed her she had not reported the allegations as she could not find a supervisor at that time. According to the DON, she told SRNA #2 to put her allegations in writing. The DON indicated at that time she had not known exactly what had happened and how many residents were involved but should have asked for more information regarding the allegations. The DON stated she had not documented her conversation with SRNA #2 on 02/25/14; however had told RN #2 to have SRNA #2 put her allegations in writing and put it under her office door. She stated she called the Administrator on 02/25/14 at approximately 10:45 PM, and told him she received a call from a SRNA about verbal abuse by SRNA #1 which had occurred the week before. The DON reported she called the Administrator again on 02/26/14 at 5:30 AM, and asked him if she should still attend the abuse conference and was told to go ahead. The DON stated she received a text message from the Administrator on 02/26/14 at 3:36 PM, and was informed he had suspended SRNA #1. According to the DON, when she arrived at the facility on 02/27/14 at 8:00 AM, she had found SRNA #2's written statement which had been placed under her door and she became aware of the allegation details then. She stated she initiated the investigation after she read SRNA #2's statement which had included two (2) verbal allegations and one (1) physical allegation. The DON stated she and the SW had not interviewed any staff who had worked the evening of 02/20/14; because the allegations had been unsubstantiated after resident interviews were completed on 02/27/14, 02/28/14 and 03/03/14. The DON indicated she had not obtained statements from RN #1 or SRNA #1 or other employees but should have. Continued interview revealed SRNA #1 had not been re-educated related to the abuse policy; and had returned to work after suspension on 03/04/14. Interview with the Administrator on 03/05/14 at 7:15 PM, on 03/08/14 at 4:30 PM and on 03/11/14 at 3:14 PM, revealed staff were to report any abuse to their Supervisor immediately and the perpetrator was to be suspended immediately pending an investigation. The Administrator stated the SS Director, DON and himself performed abuse allegation investigations. He indicated SRNA #2's allegations of SRNA #1 slamming a resident in a chair would have been physical abuse; and what she had said to Residents #12 and 15 would have been verbal abuse. However, according to the Administrator, the DON reported to him on 02/25/14, SRNA #2 had told her she had been working with SRNA #1; and felt SRNA #1's language to the residents had been inappropriate five (5) days earlier. The Administrator stated the DON informed him SRNA #2 had reported the allegations initially to the Night Supervisor who had recognized the allegations as abuse which needed to be reported. He stated the DON felt SRNA #2's allegation rose to the level of abuse but had not gone into detail of what the allegations were. He indicated he had informed the DON to go ahead to her conference the next day and she had called him again early the next morning to inquire if she should go to the conference and he told her to go ahead. He reported the DON also told him that morning SRNA #2 had slid her statement regarding the incident under her office door. The Administrator indicated he thought/expected the DON would come to the facility after her conference on 02/26/14 and initiate the investigation; however she had not returned until 02/27/14, so they had gotten a "day behind" in initiating the investigation. The Administrator stated he "figured" they could wait until 02/27/14, to start the investigation because SRNA #1 had not been in the building, and he knew she had not been scheduled to work again until the weekend per the DON. He reported he should have started the investigation of the allegations immediately himself as he believed investigations should be thoroughly investigated as it could be a potential for harm if not investigated thoroughly. He further stated he knew the facility had twenty-four (24) hours to report the allegation to State Agencies but he guessed they had "blanked out" on notifying the State Agencies; however should have ensured it was reported timely. Further interview revealed on 02/27/14, he and the DON had talked with SRNA #2 regarding the allegations and he had asked what she had overhead that made her think SRNA #1's actions had been abuse; and SRNA #2 had informed him of what she had witnessed. He stated he had asked SRNA #2 why she waited five (5) days to report the information; and she told him she had not been able to find a nurse. The Administrator stated he had asked SRNA #2 if she knew what the facility's abuse reporting policy was; but she only stated "she couldn't find a nurse". He indicated the facility's "Self Reported Incident Form" he submitted to the State Agency should not have had the incident date recorded as 02/26/14; the incident date should have been 02/20/14 as alleged. He stated the "Self Reported Incident Form" should have had the alleged incident of physical abuse of Resident #1 in it also; and he was unsure why he had left that information off the form. The Administrator stated on 02/26/14, RN #1 came to his office and stated SRNA #1 had come to work and she was supposed to have been suspended. He stated he did not know SRNA #1 had been scheduled to work 02/26/14; and he asked RN #2 to bring SRNA #1 to his office. He stated he informed SRNA #1 there had been an allegation of abuse and he was going to have to suspend her but had failed to get a statement from her as he did not want her to know what the situation was until he had investigated further. He indicated he or the DON should have called SRNA #1 when the allegations were received; and told her not to come to work until completion of the investigation. In addition, he indicated the investigation should have been more thorough because there was the potential for harm of residents if the Abuse Policy was not followed. Interview, on 03/08/14 at 11:30 AM, with the Medical Director revealed the facility had made him aware of the allegation after being informed of the Immediate Jeopardy. He stated the facility should thoroughly investigate all allegations of abuse, including interviewing residents and staff, evaluating subjective and objective data, corroborating the story, and coming up with an action plan. Continued interview revealed the State Agencies were to be notified of abuse allegations within twenty-four (24) hours. He stated, if a staff member were to witness abuse, they should immediately notify their superior, the DON and Administrator. According to the Medical Director, interviews were to be done with the perpetrator, and any staff on the unit involved in care for the residents allegedly abused. Continued interview revealed SRNA #1, the perpetrator should not have been allowed to work after administration had been notified of the allegations. The Medical Director stated, "at the point the fuse was lit, Administration should have investigated", indicating administration should have immediately started the investigation. The facility provided an acceptable credible Allegation of Compliance (AOC), on 03/12/14 which alleged removal of the Immediate Jeopardy on 03/07/14. Review of the AOC revealed the facility implemented the following: 1. The investigation was reopened on 03/05/14. Residents #12 and #15 were re-interviewed with additional questions by the DON, Administrator and/or Social Services (SS) Director on 03/06/14. Resident #1's roommate, which was the resident's sister was interviewed on 03/06/14, by the DON because Resident #1 was not interviewable. During the resident interviews on 03/06/14, no complaints or allegations against State Registered Nursing Assistant (SRNA) #1 were received. Other residents under the care of SRNA #1 with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were also interviewed from 03/01/14 to 03/06/14 by the DON, Administrator and/or SS Director with no complaints noted. All the staff working on the same hall as SRNA #1 the evening the alleged abuse occurred were interviewed by the DON, Administrator or SS Director on 03/06/14 and no complaints or concerns were verbalized. 2. SRNA #2 was counseled by the DON immediately via phone on 02/25/14, and in writing on 02/28/14, regarding compliance with the facility's Abuse Policy; and the requirement of immediately reporting all suspected abuse. The DON received education by the Nurse Consultant on 03/05/14 regarding the regulatory requirements on reporting and investigating abuse. The DON, Administrator and SS Director received in-service education by the Nurse Consultant on investigation and reporting of abuse on 03/06/14. The re-education included, but was not limited to: identification of events requiring investigation; protecting residents; interviewing residents, staff and all witnesses; and timely reporting of allegations and findings. All facility staff licensed and unlicensed received in-service education on abuse and on the facility's abuse policy, which included: immediately reporting any suspected abuse, neglect, exploitation or misappropriation; and protecting residents. The re-education was provided by the DON, Administrator and SS Director on 03/05/14 through 03/06/14. Any staff on leave, vacation, or unavailable for the in-service would not be able to clock in or work until completing the in-service education. The facility does not utilize agency staffing. 3. A weekly skin assessment performed by the Charge Nurse on 02/22/14, for Resident #1 revealed no suspicious bruising or marks which would indicate physical abuse. Routine skin assessments performed 02/21/14 through 02/27/14, by the Charge Nurses on duty, revealed no suspicious bruising or signs of potential physical abuse of the residents who might have received care by SRNA #1, 02/20/14 through 02/21/14 or any other employee. 4. The investigation was concluded on 03/06/14 with the findings unsubstantiated based on the interviews with Resident #12 and Resident #15 and other cognitively intact residents which revealed no verbal abuse by SRNA #1. Resident #1's roommate/sister had been interviewed and denied any abuse by staff. 5. All reported allegations were to be reviewed by the facility's investigation team including the Administrator, SS Director and DON immediately during normal business hours to determine which team members would investigate, and report the allegation to the required authorities. During off hours, staff was to notify the DON and/or Administrator immediately via phone; and the DON and/or Administrator would determine who should investigate and report. The Administrator was to report all findings of the facility's investigation team to the Nurse Consultant upon conclusion of the team review, within five (5) working days of the allegation, to determine that all necessary investigation and reporting interventions had been initiated. 6. The Continuous Quality Improvement (CQI) indicator for the monitoring for compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, was to be utilized with each allegation of abuse weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter under the supervision of the Administrator. Results of each abuse allegation CQI indicator was to be presented by the DON, Administrator or SS Director or design

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure policy and procedures were implemented related to abuse for three (3) of twenty-one (21) sampled residents (Residents #1 #12 and #15). The facility failed to ensure staff reported allegations of abuse, failed to interview staff in regards to the allegations received and failed to ensure other interviewable residents were interviewed timely after the notification of abuse to ensure to ensure a thorough investigation, failed to prevent the potential for further abuse, and failed to report allegations to the appropriate State Agencies per the facility's policy and procedures. On 02/25/14, at approximately 10:30 PM, State Registered Nursing Assistant (SRNA) #2 reported to House Supervisor/Registered Nurse (RN) #1, she had witnessed possible abusive incidents on 02/20/14, five (5) days earlier, involving SRNA #1 which she had not yet reported. RN #1 informed SRNA #2 what she had witnessed had been abuse and the RN notified Administration of the alleged abuse on 02/25/14. However, RN #1 failed to ensure Resident #1, who had allegedly been physically abused, was assessed as per facility policy to ensure there had been no injuries. Even though Administration had been notified on 02/25/14; there was no documented evidence the facility began an immediate investigation as per facility policy. The facility did not initiate the investigation until 02/27/14, two (2) days after receiving the allegations and only interviewed two (2) of the residents involved and the roommate of Resident #1 on 02/27/14. There was no documented evidence the facility interviewed staff and obtained documented statements from staff, who worked the evening of 02/20/14 when the incidents allegedly occurred; or obtained a documented statement from the alleged perpetrator, SRNA #1 as per facility's policy. In addition, as a result of the allegations not being reported immediately as per facility policy, the alleged perpetrator, SRNA #1, had not been removed from resident care as per the facility's policy. SRNA #1 had been allowed to continue to provide care of residents the rest of her shift on 02/20/14, an entire shift on 02/21/14 and approximately thirty (30) minutes on 02/26/14. Additionally, the facility's policy revealed State Agencies were to be notified of the allegations; however, they were not notified until 02/28/14 of the verbal abuse and were not notified of the alleged physical abuse until 03/05/14. (Refer to F-225, F-490, and F-520). Based on the above findings, it was determined the facility's failure to implement its policy and procedures regarding protecting, reporting and thoroughly investigating alleged incidents of verbal and physical abuse; and failing to immediately report the alleged incidents to the State Agencies, was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/05/14 and was determined to exist on 02/20/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 03/12/14 with the facility alleging removal of the Immediate Jeopardy on 03/07/14. The Immediate Jeopardy was verified to be removed on 03/07/14 prior to exiting the facility on 03/13/14, with remaining non-compliance at CFR 483.13, Resident Behavior and Facility Practice, F-226 Abuse, with a Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure abuse policy and procedures are implemented. The findings include: Review of the facility's policy titled, "Policy on Abuse", undated, revealed if staff observed possible abuse they were to report the abuse to their supervisor, Social Services (SS), Director of Nursing (DON) and Administrator immediately. Review of the policy revealed the Administrator, DON and SS Director were to conduct immediate investigations of abuse or neglect allegations when identified during the shift on which the alleged abuse occurred, to include interviews with the resident or other resident witnesses which were to have been documented. Review of the policy revealed the facility was to ensure a thorough examination of the resident had been performed after an allegation of physical abuse. Policy review revealed allegations were to be reported to the appropriate State Agencies; and, the Administrator was responsible for ensuring the facility's compliance. According to the policy, written documentation was to be obtained from all persons with knowledge of the reported incident, which was to include the staff person implicated. Further review of the policy revealed if a staff person had been implicated, the employee was to be removed from resident care and sent home after completing a written statement. Review of the facility's investigation, "Combined Incident Report/Final Report" which was submitted to the State Agencies on 02/28/14, revealed SRNA #2 had been working with SRNA #1, and felt SRNA #1 had been inappropriate in her conversations with Resident #12 and Resident #15. Review of the incident date on the Report revealed it was documented as 02/26/14, not 02/20/14 as alleged by SRNA #2. Continued review of the Report revealed the House Supervisor reported to the Administrator; and, SRNA #1 had been immediately suspended to protect the residents. According to the Report, the DON and the Social Worker (SW) interviewed the two (2) residents involved; and they stated no staff member had said or done anything to them they felt had been inappropriate. Per the Report, the facility's "conclusion" had been to return SRNA #1 to work on day shift and on the other unit to monitor her closely; and to offer training in proper technique by the Staff Development Director. Further review of the Report revealed no documented evidence of the physical abuse allegation involving Resident #1; of a written statement from SRNA #2; or of written statements from other employees working when the allegations occurred. Further review of the facility's investigation revealed an "Abuse Investigation and Reporting Checklist" completed by the DON which indicated the staff person had not immediately reported the alleged incident to her immediate supervisor and the incident allegedly occurred on 02/20/14, however had not been reported until 02/25/14 to the supervisor. Review of the Checklist revealed no documented evidence of when the investigation had been initiated, or of dates and times of when it had been initiated to indicate the investigation had been initiated immediately as per facility policy. Continued review of the Checklist revealed the Administrator, DON, and SS, Physician and State Agencies had been notified; however, there was no documented evidence of the dates and times of the notifications to indicate when the notifications had occurred. The checklist revealed SRNA #1, the alleged perpetrator, had been suspended for three (3) days on 02/26/14, 02/27/14, and 02/28/14; however there was no documented evidence the SRNA had been removed from resident care and sent home after completing a written statement as per facility policy. Review of the facility's investigation revealed only interviews with Resident #12, Resident #15, and Unsampled Resident I, roommate of Resident #1, had been conducted on 02/27/14. Continued review of the investigation revealed no documented evidence other residents who might have been witnesses of the alleged abuse had been interviewed until 03/03/14, six (6) days after the facility had been notified of the allegations. Review of the written statement from SRNA #2, undated, revealed on 02/20/14 SRNA #2 had heard SRNA #1 tell Resident #15 she was not going to keep putting him/her on the bedpan as she did not have time to fool with his/her "stinking ass". Continued review of the written statement, revealed SRNA #1 had told Resident #12 "to open" his/her legs so she could clean his/her "coochie". Further review of the statement from SRNA #2 revealed SRNA #1 had been very rough with Resident #1 when transferring him/her, practically slamming the resident in his/her chair causing him/her to cry out very loud as if in pain. Additionally, review of the written statement revealed SRNA #2 had requested not to work with SRNA #1 again. Interview with SRNA #2 on 03/05/14 at 3:30 PM and on 03/14/14 at 1:23 PM, revealed she knew if she was to witness abuse, she would need to report it immediately to the Charge Nurse or DON. SRNA #2 stated, however one day sometime after dinner, she had witnessed SRNA #1 tell Resident #15, she did not have time to fool with him/her, taking his/her "stinking ass" off the bedpan all the time. She stated she also heard SRNA #1 tell Resident #12 "to open" his/her legs, so she could clean his/her "coochie" that same evening. SRNA #2 indicated she felt like this had been inappropriate and abusive. SRNA #2 stated also, that same evening, SRNA #1 had been transferring Resident #1 by herself and had picked the resident up and slammed him/her down. She stated she had been startled when Resident #1 made a noise after being slammed down as if he/she had been uncomfortable or in pain. SRNA #2 stated she felt SRNA #1 had been very rough and felt this would have been considered abusive. However, SRNA #2 stated she had not reported what she had witnessed until 02/25/14, when she reported it to Registered Nurse (RN) #1 sometime in the evening. She stated RN #1 told her this had been abuse which needed to be reported; RN #1 placed a call to the DON and had her tell the DON what she had witnessed. However, SRNA #2 stated the DON informed her she would talk to her about what she had witnessed when she (DON) returned to work. She stated the next day RN #1 asked her to write a statement as to what she had witnessed. Continued interview revealed the Administrator had talked with her and told her he would be investigating what she had witnessed; however, she was unsure what date and time this had occurred. She further stated she had been suspended by the Administrator on 03/03/14. Interview with SRNA #1 on 03/05/14 at 1:50 PM and 03/14/14 at 10:34 AM, revealed she had received training on abuse at the facility on hire and knew if someone told a resident they did not have time to fool with their "stinking ass" or transferred residents roughly it would be considered abuse. She stated on 02/26/14, while she had been caring for her residents the Administrator called her to his office and had sent her home for talking "badly" to residents. SRNA #1 stated there had been no discussion of what the allegations were or which residents were involved and she had been told the DON would investigate and then talk to her. She indicated the Administrator had told her it was confidential. She stated she called the DON on 02/27/14 to ask what she had been accused of and the DON told her she was still investigating and would let her know later. SRNA #1 stated she did not recall the DON asking for her side of the story and no one had asked her to write a statement in regards to the allegations. Further interview revealed she talked to the DON again, on 03/01/14, and was told the investigation had determined the allegations were not true and she should report to work on 03/02/14. Additionally, interview revealed SRNA #1 denied the allegations related to Resident #1, Resident #12 and Resident #15. Interview with SRNA # 5 on 03/05/14 at 3:11 PM; Licensed Practical Nurse (LPN) #4 on 03/05/14 at 6:27 PM; and LPN #5 on 03/05/14 at 2:43 PM, revealed they all had worked the evening of 02/20/14, and had not been interviewed during the facility's initial investigation. Interview with RN #1/House Supervisor on 03/05/14 at 3:50 PM, on 03/08/14 at 3:15 PM, and on 03/11/14 at 1:48 PM, revealed SRNA #2 told her on 02/25/14 she had witnessed SRNA #1 on 02/20/14 being verbally abusive to three (3) residents, Residents #12 and Resident #15; and physically abusive to Resident #1. RN #1 stated she had called the DON and had SRNA #2 report the allegations to the DON. According to RN #1 she asked the DON if she needed to complete anything and the DON had told her no, she would take of it and report the allegations to the Administrator. She stated the DON told her SRNA #2 should have reported the abuse she had witnessed a week ago when she witnessed it. RN #1 stated the DON informed her she did not think she would report this allegation to the "State". RN #1 stated she had not done anything else as it had been time for SRNA #1's shift to end. She stated she had not completed a skin assessment of Resident #1 after having been informed of the alleged physical abuse of the resident; however, she should have per facility policy. RN #1 stated on 02/26/14 she had observed SRNA #1 come in to work and begin caring for residents. She stated she went immediately to the Administrator, who was on the phone, to report this; and indicated it had been approximately 4:00 PM when she was able to talk to him. RN #1 reported she had told the Administrator SRNA #1 needed to be suspended right away related to the abuse allegations and he told her he was aware of the allegations. She indicated the Administrator had SRNA #1 brought to his office and he suspended her then. RN #1 stated SRNA #1 should have been immediately suspended pending the investigation; and the facility had not followed its policy. Interview with RN #2/Unit Manager on 03/05/14 at 10:20 AM, 6:52 PM and on 03/08/14 at 2:30 PM, revealed RN #1 had been furious upon arriving to work on 02/26/14, and realizing SRNA #1 had been working. She stated RN #1 had asked her why SRNA #1 was there; and went to the Administrator's office immediately. RN #2 stated she had taken SRNA #1 to the Administrator's office per his request and indicated SRNA #1 had been told allegations of abuse had been made against her and she was to be suspended per the facility's policy until completion of the investigation. RN #2 stated she had not been informed of what the allegations were and therefore had not known SRNA #1 should not have been caring for residents on 02/26/14. According to RN #2, SRNA #1 should not have been at work on 02/26/14, after Administration had been informed of the allegations. She indicated she felt the facility had not followed the abuse protocol. Review of SRNA #1's time card revealed she worked on 02/26/14 from 3:00 PM to 3:30 PM. Interview with the SS Director on 03/05/14 at 2:50 PM, revealed transferring someone in a rough manner; and inappropriate use of terminology for private parts would be examples of abuse and should be reported immediately. She stated the DON oversaw abuse investigations; however the DON, Administrator and she collaborated as a team for conducting abuse investigations. The SS Director stated the Administrator was to submit an initial investigation to the State Agencies in twenty-four (24) hours. The SS Director stated she had been notified of the allegations involving SRNA #1 on 02/26/14, while she had been out of the facility at a conference with the DON. She stated SRNA #2 should have reported the allegations immediately on 02/20/14, when they allegedly occurred; and the facility's investigation should have been initiated on 02/25/14 when SRNA #2 finally reported them. She stated the alleged perpetrator should have been immediately suspended pending the investigation, per facility policy. The SS Director indicated the residents involved had not been interviewed until 02/27/14 when she and the DON returned to the facility. The SS Director stated she interviewed all interviewable residents residing on the hall on which SRNA #1 had worked on 02/20/14, except for Resident #15 who the DON interviewed. However, she did not indicate when the resident interviews had occurred. She stated she had not been aware staff interviews had not been completed; and indicated several staff working on 02/20/14 should have been interviewed as per the policy. The SS Director stated she also was unaware SRNA #1 had not been interviewed; and stated the alleged perpetrator should have been interviewed immediately. Continued interview revealed she was also not aware the facility had failed to immediately report the allegations to the State Agencies as per the policy. She stated the facility's policy should have been followed. Interview with the DON on 03/05/14 at 10:30 AM, 6:30 PM, 03/11/14 at 3:00 PM, 03/13/14 at 1:53 PM, revealed if staff witnessed potential abuse they were to immediately notify their supervisor who should immediately notify the Administrator. She stated the supervisor should start the investigation immediately; and stated the facility had twenty-four (24) hours to notify the State Agencies. The DON stated after an allegation of abuse had been reported, the perpetrator was to be suspended until the investigation was completed. She stated the Administrator was the "leader" in abuse investigation and she was responsible for starting the abuse packet which included the "Abuse Investigation and Reporting Checklist". However she stated she had not received any in-service or guidelines on how to complete the checklist and abuse packet and indicated the dates and times of notifications should have been included on the "Abuse Investigation and Reporting Checklist" in her investigation packet. She stated she had been notified on 02/25/14 at 10:30 PM, of the alleged verbal abuse when RN #1 and SRNA #2 called her. She stated SRNA #2 reported to her SRNA #1 had been verbally abusive last week; and she informed SRNA #2 she should have reported the abuse to her supervisor right away when she witnessed the abuse as per the policy. The DON stated SRNA #2 told her she had not reported the abuse right away because she had been unable to find a supervisor to report it to at the time. The DON stated she had not documented what she had been told; however she told SRNA #2 to put what she had witnessed in writing. She stated she told RN #2 also to have SRNA #2 write a statement of her allegations and put it under her office door. She stated at that time she had not known the details of what happened and should have asked more questions. She stated she called the Administrator on 02/25/14 at approximately 10:45 PM, and informed him of what SRNA #2 had told her she had witnessed SRNA #1 do which had occurred the week before. The DON stated when she returned to work on 02/27/14 at 8:00 AM she read SRNA #2's written statement which included two (2) verbal abuse and one (1) physical abuse allegation and started the investigation, two (2) days after the facility had been notified of the allegations. She stated she had not obtained written statements from RN #1 or SRNA #1; however, she should have, as well as, obtained written statements from other staff who had worked the evening of 02/20/14. The DON stated SRNA #1 should not have worked after the facility was notified of the allegations pending the investigation results. Interview with the Administrator on 03/05/14 at 7:15 PM, 03/08/14 at 4:30 PM and 03/11/14 at 3:14 PM, revealed staff was to report any abuse to their supervisor immediately; and the perpetrator was to be suspended immediately pending an investigation. The Administrator stated the DON reported to him on 02/25/14, SRNA #2 had told her she had been working with SRNA #1 and had felt SRNA #1's language to the residents had been inappropriate. He stated the DON felt SRNA #2's allegation had risen to the level of abuse and had occurred five (5) days before. The Administrator stated SRNA #2 had reported the allegations initially to the Night Supervisor who had identified the allegations as abuse which needed to be reported; however, he stated the DON had not gone into detail about what the allegations were and indicated he had not asked. He stated the allegations made by SRNA #2 would have been examples of verbal and physical abuse and SRNA #1 should have been suspended immediately as per the facility policy. The Administrator stated he had informed the DON to go ahead to the conference on 02/26/14, and he would deal with the allegations the next morning; however he did not, as he thought the DON would initiate the investigation on 02/26/14 after the conference. He stated, she did not return to the facility until 02/27/14 so they had gotten a day behind in initiating the investigation. The Administrator stated he thought initiation of the investigation could wait until 02/27/14, as well as suspending SRNA #1 as she had not been scheduled to work again until the weekend per the DON. He indicated, he knew this was not the facility's policy. He stated he knew the facility had twenty-four (24) hours to report the allegations to the State Agencies; but he guessed they had "blanked out" on notifying the State Agencies as per the policy. The Administrator stated on 02/27/14, he and the DON had talked with SRNA #2 regarding the allegations; however, he had not documented the interview. He stated he had asked SRNA #2 why she had waited five (5) days to report the allegations; and she told him she had not been able to find a nurse to report it to. He stated as part of the investigation they should have interviewed staff who worked the evening of 02/20/14; and obtained their written statements, as per policy. He indicated they had not talked to any of those staff members until 03/01/14 and 03/02/14; and had not written the interviews down. The Administrator stated on 02/26/14, RN #1 came to his office and stated SRNA #1 had come to work and should have been suspended. He stated after RN #1 telling him SRNA #1 had been working, he had SRNA #1 brought to his office, informed her an allegation of abuse had been made and suspended SRNA #1. He reported, however he had failed to get a written statement from SRNA #1 at that time; but had not wanted the SRNA to know what the situation was until he had investigated further. The Administrator stated he or the DON should have called SRNA #1 immediately to inform her she had been suspended until the investigation had been completed as per the policy. He indicated the facility's investigation submitted to the State Agency should have had the incident date recorded as 02/20/14, not 02/26/14; and should have included the allegation of physical abuse of Resident #1. He indicated he was unsure why he had left that information off the report submitted to the State Agency on 02/28/14, three (3) days after the abuse allegations had been made. He indicated he felt the facility's investigation had not been thorough in hindsight. The Administrator stated by not thoroughly investigating and timely reporting the allegations as per the policy, there could be the potential for harm for residents. The facility provided an acceptable credible Allegation of Compliance (AOC), on 03/12/14 which alleged removal of the Immediate Jeopardy on 03/07/14. Review of the AOC revealed the facility implemented the following: 1. The investigation was reopened on 03/05/14. Residents #12 and #15 were re-interviewed with additional questions by the DON, Administrator and/or Social Services (SS) Director on 03/06/14. Resident #1's roommate, which was the resident's sister was interviewed on 03/06/14, by the DON because Resident #1 was not interviewable. During the resident interviews on 03/06/14, no complaints or allegations against State Registered Nursing Assistant (SRNA) #1 were received. Other residents under the care of SRNA #1 with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were also interviewed from 03/01/14 to 03/06/14 by the DON, Administrator and/or SS Director with no complaints noted. All the staff working on the same hall as SRNA #1 the evening the alleged abuse occurred were interviewed by the DON, Administrator or SS Director on 03/06/14 and no complaints or concerns were verbalized. 2. SRNA #2 was counseled by the DON immediately via phone on 02/25/14, and in writing on 02/28/14, regarding compliance with the facility's Abuse Policy; and the requirement of immediately reporting all suspected abuse. The DON received education by the Nurse Consultant on 03/05/14 regarding the regulatory requirements on reporting and investigating abuse. The DON, Administrator and SS Director received in-service education by the Nurse Consultant on investigation and reporting of abuse on 03/06/14. The re-education included, but was not limited to: identification of events requiring investigation; protecting residents; interviewing residents, staff and all witnesses; and timely reporting of allegations and findings. All facility staff licensed and unlicensed received in-service education on abuse and on the facility's abuse policy, which included: immediately reporting any suspected abuse, neglect, exploitation or misappropriation; and protecting residents. The re-education was provided by the DON, Administrator and SS Director on 03/05/14 through 03/06/14. Any staff on leave, vacation, or unavailable for the in-service would not be able to clock in or work until completing the in-service education. The facility does not utilize agency staffing. 3. A weekly skin assessment performed by the Charge Nurse on 02/22/14, for Resident #1 revealed no suspicious bruising or marks which would indicate physical abuse. Routine skin assessments performed 02/21/14 through 02/27/14, by the Charge Nurses on duty, revealed no suspicious bruising or signs of potential physical abuse of the residents who might have received care by SRNA #1, 02/20/14 through 02/21/14 or any other employee. 4. The investigation was concluded on 03/06/14 with the findings unsubstantiated based on the interviews with Resident #12 and Resident #15 and other cognitively intact residents which revealed no verbal abuse by SRNA #1. Resident #1's roommate/sister had been interviewed and denied any abuse by staff. 5. All reported allegations were to be reviewed by the facility's investigation team including the Administrator, SS Director and DON immediately during normal business hours to determine which team members would investigate, and report the allegation to the required authorities. During off hours, staff was to notify the DON and/or Administrator immediately via phone; and the DON and/or Administrator would determine who should investigate and report. The Administrator was to report all findings of the facility's investigation team to the Nurse Consultant upon conclusion of the team review, within five (5) working days of the allegation, to determine that all necessary investigation and reporting interventions had been initiated. 6. The Continuous Quality Improvement (CQI) indicator for the monitoring for compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, was to be utilized with each allegation of abuse weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter under the supervision of the Administrator. Results of each abuse allegation CQI indicator was to be presented by the DON, Administrator or SS Director or designee; and reviewed with the QA team as part of the daily meetings Monday through Friday. Failure to meet the established threshold of one hundred percent (100 %) on the CQI indicator tool would result in intervention; and an immediate internal plan of correction to address the identified areas of concern. The findings of the completed CQI indicators were to be reviewed by the contracted Nurse Consultant with monthly visits, to determine that allegations were investigated and reported as indicated. The effectiveness of the facility's administration would be monitored through the CQI process. Results were to be reported to the QA Committee by the Administrator, DON, SS Director or designee. 7. The facility's QA team with the Medical Director convened on 03/06/14 to review the circumstances of the allegations, and all interventions which had been and were to be implemented by the facility. 8. The Contracted Nursing Consultant and or Nursing Home Administrator (NHA) consultant will conduct an evaluation of the facility's CQI program monthly for three (3) months, then annually thereafter. Results will be reported to the QA committee. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's documentation revealed the investigation had been re-opened. Review revealed Resident #12 and Resident #15 were re-interviewed on 03/06/14 by the SS Director with additional specific questions and no concerns identified. Review of the documentation revealed Resident #1's roommate/sister had been re-interviewed on 03/06/14 by the SS Director with no concerns noted. Additionally, review revealed seventeen (17) other residents with a BIMS of eight (8) or above had been interviewed between 03/01/14 and 03/06/14 with no concerns identified. Further review revealed all staff members who had worked the West Wing evening shift on 02/20/14, where SRNA #1 allegedly abused residents, were interviewed and had signed Witness Statements, dated 03/06/14. 2. Review of the "Improvement Plan" dated 02/26/14, revealed SRNA #2 had been counseled for not reporting concerns to the supervisor immediately in regards to verbal remarks from another SRNA; and for not following facility policy related to abuse. The Plan was marked as "first counseling" and signed by the DON on 02/28/14. Continued review revealed the DON had attempted to provide a written counseling with SRNA #2 on 02/28/14; however the employee refused to sign it. Interview with the DON on 03/13/14 at 2:20 PM, revealed she had talked to SRNA #2 about abuse on 02/28/14 and attempted to have her sign a written counseling; however SRNA #2 had refused to sign it. Review of a sign-in sheet dated 03/06/14, revealed the Administrator, DON and SS Director had attended the Nurse Consultant's inservice on abuse. Interview with the DON on 03/13/14 at 11:30 AM revealed she had received an inservice from the Nurse Consultant on 03/05/14 and 03/06/14 via phone conference call. She stated the Nurse Consultant educated her on abuse, investigation of abuse, getting statements from residents and staff related to the incident; and regulatory requirements. She stated the Nurse Consultant had also talked about events which would require investigation, types of abuse, how to suspect abuse, protecting residents, and reporting abuse to State Agencies. Interview with the Administrator on 03/12/14 at 5:27 PM, and the SS Director on 03/12/14 at 4:29 PM, revealed they had a conference with the Nurse Consultant on 03/06/14; and were educated on identifying abuse, the different types of abuse, what needed to be investigated, interviewing all the staff working with the residents, interviewing residents, having staff turn in a written statement related to the abuse, reporting abuse and time frames for reporting abuse. Interview with the Nurse Consultant on 03/13/14 at 9:30 AM, revealed she had given training to the Administrator, SS Director and DON on 03/06/14. She further stated the training on abuse had included identification, documentation, conducting interviews, investigation, and timely reporting requirements of abuse. Review of the facility's inservice education related to abuse revealed it had included the policies on abuse, reporting and investigating abuse, examples of abuse. Review of the facility's documentation revealed staff had taken a post test after the education and signed an acknowledgement form. Continued review of the documentation revealed staff attendance signatures which indicated they had received the abuse inservice on 03/05/14 and 03/06/14. Further review of the inservice education sign-in sheets revealed dietary, housekeeping, nurses, SRNAs, office staff, activities, SS, medical records, laundry and therapy staff had received the education. Additionally, review revealed staff who had not received the education on 03/05/14 and 03/06/14 were inserviced prior to returning to work on 03/07/14 through 03/13/14. Interview with the Staff Development Nurse on 03/13/14 at 2:05 PM, revealed she had a master list of staff with signatures of everyone who had been inserviced; and she had inserviced everyone who had worked so far. The Staff Development Nurse stated the facility had some "PR

Based on interview, record review and review of the facility's policy, it was determined the for three (3) of twenty-four (24) sampled residents (Resident #15 #12 and #1). State Registered Nursing Assistant (SRNA) #2, on 02/25/14 at approximately 10:30 PM, notified Registered Nurse (RN) #1, that five (5) days earlier on 02/20/14, she had witnessed SRNA #1 verbally abuse Resident #15 and Resident #12; and witnessed SRNA #1 being physically abusive to Resident #1. The facility's Administration failed to ensure Resident #1 was assessed for injury after the facility became aware of the physical allegation. As a result of SRNA #2's delay in reporting these allegations, SRNA #1 was not removed from care of residents and worked on 02/20/14 and 02/21/14. Although the facility's Administration was notified on 02/25/14, of the alleged abuse which occurred on 02/20/14, SRNA #1 was allowed to report to work and care for residents on 02/26/14 from 3:00 PM to 3:30 PM before being suspended. Therefore, the facility's Administration failed to ensure residents were protected from potential abuse during the investigation. Also, interview and record review revealed the facility's Administration failed to immediately investigate the allegations; and failed to report all the allegations immediately to State Agencies as per state law. The facility's Administration failed to conduct a comprehensive investigation by only interviewing residents who were interviewable; and not including interviews with staff who had worked at the time of the allegations. Additionally, the facility's Administration failed to ensure a written statement was obtained from SRNA #1, the alleged perpetrator, as per policy. The facility's Administration also failed to ensure re-education of the facility's abuse policies was provided to the staff involved and to other staff after being notified of the allegations on 02/25/14 to ensure the policies were implemented in the future. (Refer to F-225, F-226, and F-520). The facility's Administration's failure to have an effective system in place to ensure the facility's policies were implemented; and, failure to ensure its resources were utilized effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 03/05/14, and was determined to exist on 02/20/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 03/12/14 with the facility alleging removal of the Immediate Jeopardy on 03/07/14. The Immediate Jeopardy was verified to be removed on 03/07/14, prior to exiting the facility on 03/13/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-490 Administration, with a Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance Committee continues to monitor to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Policy on Abuse", undated, revealed all personnel were to immediately report any incident or suspected incidents of resident abuse to their Supervisor, Social Services (SS), the Director of Nursing (DON) and Administrator. Continued review revealed an incident report form was to be initiated by the Charge Nurse upon receiving a report of suspected abuse. Review of the Policy revealed the Administrator, DON and SS Director were to conduct an immediate investigation of abuse or neglect allegations. The Policy further stated the Administrator, DON and/or SS Director were to report incident/allegation to the appropriate State Agencies. Additionally, the Policy indicated written statements were to be obtained from all persons with knowledge of the reported incident. Review of the facility's investigation, "Combined Incident Report/Final Report" form submitted to the State Agencies on 02/28/14 at 5:39 PM, revealed the form listed the "incident date" as 02/26/14, instead of 02/20/14 as per report of SRNA #2. Review of the form revealed SRNA #2 was working the same rooms as SRNA #1 and felt SRNA #1's conversation with the residents involved was not "appropriate". Continued review revealed the shift was over when this was reported to the House Supervisor. Review revealed the House Supervisor reported this information to the Administrator; and SRNA #1 was "suspended" for three days "immediately" to protect the residents. According to the form, the DON and the Social Worker (SW) interviewed the two (2) residents and they indicated no staff member had said or done anything to them that they felt was inappropriate. Review of the form revealed SRNA #2 and the House Supervisor, Registered Nurse (RN) #1, were friends and RN #1 had "had words" with SRNA #1 before. The form stated the facility's conclusion was to return SRNA #1 to work on the day shift and on the other unit to monitor her closely and to offer training in proper technique provided by the Staff Development Director. Further review of the form, revealed no documented evidence of the allegation of physical abuse of Resident #1. However, on 03/05/14 at 10:30 AM, per the request of the Surveyor, for a copy of the completed investigation, a copy of SRNA #2's written statement was received which indicated the alleged physical abuse regarding Resident #1. Interview with SRNA #2, on 03/05/14 at 3:30 PM, revealed on 02/20/14 she had witnessed SRNA#1 being verbally abusive to Resident #15 and Resident #12; and physically abusive to Resident #1. SRNA #2 stated she did not report the abuse until 02/25/14, when she told Registered Nurse (RN) #1 about the allegations. SRNA #2 explained she had received abuse training on hire and knew she was to report any abuse immediately; however, she had failed to report the abuse. Further interview revealed RN #1 had ensured SRNA #2 notified the DON immediately of the allegations. Interview with RN #1, on 03/05/14 at 3:50 PM, revealed she immediately called the DON on 02/25/14, after SRNA #2 notified her of the allegations. According to RN #1, the DON informed her she would notify the Administrator. Interview with the DON, on 03/05/14 at 10:30 AM and 6:30 PM; and 03/07/14 at 12:50 PM, revealed she was notified on 02/25/14 at 10:30 PM by RN #1 and SRNA #2 of the verbal abuse allegations; however, she was not notified of the physical abuse allegation at that time. The DON stated she was unaware of the physical abuse allegation until 02/27/14 when she read SRNA #2's written statement. She stated the investigation was not started until 02/27/14 after she and the SS Director returned from a conference, two (2) days after learning of the allegations. According to the DON, the facility's investigation consisted of interviewing interviewable residents and this did not identify any concerns. The DON stated none of the staff who worked the evening of 02/20/14 was interviewed. She stated there had been a conflict between SRNA #1 and RN #1 and because of that, and the residents expressing no concerns, the facility unsubstantiated the allegations. She indicated she was unaware the facility had not been in compliance with reporting the alleged abuse to State Agencies. The DON stated she thought the facility had five (5) days to report to the State Agencies from the time facility Administration was notified of the allegations. The DON revealed she had not obtained a written statement from SRNA #1. She stated SRNA #1 had been off work on 02/25/14, had been suspended on 02/26/14, and had not returned to work until 03/04/14. The DON stated the facility had not provided follow up abuse inservices or re-education for staff including SRNA #1 and SRNA #2 following the investigation. Interview, on 03/05/14 at 7:15 PM and 03/08/14 at 4:30 PM, and 03/11/14 at 3:14 PM with the Administrator revealed the DON called him on 02/25/14, and stated she was informed SRNA #2 had been working with SRNA #1; and felt SRNA #1's language to the residents was inappropriate. According to the Administrator the DON felt SRNA #2's allegation rose to the level of abuse. Further interview revealed the DON informed him the allegation was made on 02/25/14; although the incidents had occurred five (5) days earlier, on 02/20/14. He stated he told the DON, she and the SS Director were to go ahead and attend a conference the next day; and he would look into the allegations the next morning. The Administrator stated SRNA #1 worked on 02/25/14, so he decided to wait for the DON to start the investigation when she returned to the facility on [DATE], since the perpetrator would not be working until the weekend. Continued interview revealed the DON and the SS Director did not return to the facility until 02/27/14, and this had "put them a day behind" with the investigation. He stated he was aware the facility had about twenty-four (24) hours to report allegations to the State Agencies; but his thinking was clouded because he felt it was not truly abuse. He indicated he thought it had all been due to a conflict with staff, between SRNA #1 and RN #1. The Administrator stated the investigation consisted only of talking to interviewable residents, including Resident #12 and #15 and Resident 1 (sister and roommate of Resident #1) on 02/27/14, and later interviews were obtained with other interviewable residents. He stated a written statement was not obtained from SRNA #1; however, it should have been as part of the facility's investigation. According to the Administrator, all the staff who worked the evening of 02/20/14 should have been interviewed and statements obtained. He indicated he felt the facility should have completed a more thorough investigation into the allegations made on 02/25/14; to have included the interviews with all staff involved and working that night. He stated SRNA #1 came to work on 02/26/14; however, he thought she had not been scheduled to work again until the weekend, and had not contacted her related to suspending her pending the investigation. The Administrator stated someone notified him SRNA #1 had been on the unit working on 02/26/14; and he stated he had her brought to the office and suspended her at that time. Continued interview and review of the "Combined Incident Report/Final Report" form with the Administrator revealed he had mistakenly indicated the incident date was 02/26/14; but it should have been 02/20/14. He stated he was unsure of why he left out the physical abuse of Resident #1 on the "Combined Incident Report/Final Report" which he submitted to the State Agencies on 02/28/14. The Administrator stated investigations of abuse were to be thoroughly investigated and reported timely. In addition, he stated the State Agencies should have been notified timely, the investigation should have been more thorough, and the alleged perpetrator should have been suspended pending investigation at the time Administration became aware of the allegation because there was the potential for harm of residents if the Abuse Policy was not followed. The facility provided an acceptable credible Allegation of Compliance (AOC), on 03/12/14 which alleged removal of the Immediate Jeopardy on 03/07/14. Review of the AOC revealed the facility implemented the following: 1. The investigation was reopened on 03/05/14. Residents #12 and #15 were re-interviewed with additional questions by the DON, Administrator and/or Social Services (SS) Director on 03/06/14. Resident #1's roommate, which was the resident's sister was interviewed on 03/06/14, by the DON because Resident #1 was not interviewable. During the resident interviews on 03/06/14, no complaints or allegations against State Registered Nursing Assistant (SRNA) #1 were received. Other residents under the care of SRNA #1 with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were also interviewed from 03/01/14 to 03/06/14 by the DON, Administrator and/or SS Director with no complaints noted. All the staff working on the same hall as SRNA #1 the evening the alleged abuse occurred were interviewed by the DON, Administrator or SS Director on 03/06/14 and no complaints or concerns were verbalized. 2. SRNA #2 was counseled by the DON immediately via phone on 02/25/14, and in writing on 02/28/14, regarding compliance with the facility's Abuse Policy; and the requirement of immediately reporting all suspected abuse. The DON received education by the Nurse Consultant on 03/05/14 regarding the regulatory requirements on reporting and investigating abuse. The DON, Administrator and SS Director received in-service education by the Nurse Consultant on investigation and reporting of abuse on 03/06/14. The re-education included, but was not limited to: identification of events requiring investigation; protecting residents; interviewing residents, staff and all witnesses; and timely reporting of allegations and findings. All facility staff licensed and unlicensed received in-service education on abuse and on the facility's abuse policy, which included: immediately reporting any suspected abuse, neglect, exploitation or misappropriation; and protecting residents. The re-education was provided by the DON, Administrator and SS Director on 03/05/14 through 03/06/14. Any staff on leave, vacation, or unavailable for the in-service would not be able to clock in or work until completing the in-service education. The facility does not utilize agency staffing. 3. A weekly skin assessment performed by the Charge Nurse on 02/22/14, for Resident #1 revealed no suspicious bruising or marks which would indicate physical abuse. Routine skin assessments performed 02/21/14 through 02/27/14, by the Charge Nurses on duty, revealed no suspicious bruising or signs of potential physical abuse of the residents who might have received care by SRNA #1, 02/20/14 through 02/21/14 or any other employee. 4. The investigation was concluded on 03/06/14 with the findings unsubstantiated based on the interviews with Resident #12 and Resident #15 and other cognitively intact residents which revealed no verbal abuse by SRNA #1. Resident #1's roommate/sister had been interviewed and denied any abuse by staff. 5. All reported allegations were to be reviewed by the facility's investigation team including the Administrator, SS Director and DON immediately during normal business hours to determine which team members would investigate, and report the allegation to the required authorities. During off hours, staff was to notify the DON and/or Administrator immediately via phone; and the DON and/or Administrator would determine who should investigate and report. The Administrator was to report all findings of the facility's investigation team to the Nurse Consultant upon conclusion of the team review, within five (5) working days of the allegation, to determine that all necessary investigation and reporting interventions had been initiated. 6. The Continuous Quality Improvement (CQI) indicator for the monitoring for compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, was to be utilized with each allegation of abuse weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter under the supervision of the Administrator. Results of each abuse allegation CQI indicator was to be presented by the DON, Administrator or SS Director or designee; and reviewed with the QA team as part of the daily meetings Monday through Friday. Failure to meet the established threshold of one hundred percent (100 %) on the CQI indicator tool would result in intervention; and an immediate internal plan of correction to address the identified areas of concern. The findings of the completed CQI indicators were to be reviewed by the contracted Nurse Consultant with monthly visits, to determine that allegations were investigated and reported as indicated. The effectiveness of the facility's administration would be monitored through the CQI process. Results were to be reported to the QA Committee by the Administrator, DON, SS Director or designee. 7. The facility's QA team with the Medical Director convened on 03/06/14 to review the circumstances of the allegations, and all interventions which had been and were to be implemented by the facility. 8. The Contracted Nursing Consultant and or Nursing Home Administrator (NHA) consultant will conduct an evaluation of the facility's CQI program monthly for three (3) months, then annually thereafter. Results will be reported to the QA committee. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's documentation revealed the investigation had been re-opened. Review revealed Resident #12 and Resident #15 were re-interviewed on 03/06/14 by the SS Director with additional specific questions and no concerns identified. Review of the documentation revealed Resident #1's roommate/sister had been re-interviewed on 03/06/14 by the SS Director with no concerns noted. Additionally, review revealed seventeen (17) other residents with a BIMS of eight (8) or above had been interviewed between 03/01/14 and 03/06/14 with no concerns identified. Further review revealed all staff members who had worked the West Wing evening shift on 02/20/14, where SRNA #1 allegedly abused residents, were interviewed and had signed Witness Statements, dated 03/06/14. 2. Review of the "Improvement Plan" dated 02/26/14, revealed SRNA #2 had been counseled for not reporting concerns to the supervisor immediately in regards to verbal remarks from another SRNA; and for not following facility policy related to abuse. The Plan was marked as "first counseling" and signed by the DON on 02/28/14. Continued review revealed the DON had attempted to provide a written counseling with SRNA #2 on 02/28/14; however the employee refused to sign it. Interview with the DON on 03/13/14 at 2:20 PM, revealed she had talked to SRNA #2 about abuse on 02/28/14 and attempted to have her sign a written counseling; however SRNA #2 had refused to sign it. Review of a sign-in sheet dated 03/06/14, revealed the Administrator, DON and SS Director had attended the Nurse Consultant's inservice on abuse. Interview with the DON on 03/13/14 at 11:30 AM revealed she had received an inservice from the Nurse Consultant on 03/05/14 and 03/06/14 via phone conference call. She stated the Nurse Consultant educated her on abuse, investigation of abuse, getting statements from residents and staff related to the incident; and regulatory requirements. She stated the Nurse Consultant had also talked about events which would require investigation, types of abuse, how to suspect abuse, protecting residents, and reporting abuse to State Agencies. Interview with the Administrator on 03/12/14 at 5:27 PM, and the SS Director on 03/12/14 at 4:29 PM, revealed they had a conference with the Nurse Consultant on 03/06/14; and were educated on identifying abuse, the different types of abuse, what needed to be investigated, interviewing all the staff working with the residents, interviewing residents, having staff turn in a written statement related to the abuse, reporting abuse and time frames for reporting abuse. Interview with the Nurse Consultant on 03/13/14 at 9:30 AM, revealed she had given training to the Administrator, SS Director and DON on 03/06/14. She further stated the training on abuse had included identification, documentation, conducting interviews, investigation, and timely reporting requirements of abuse. Review of the facility's inservice education related to abuse revealed it had included the policies on abuse, reporting and investigating abuse, examples of abuse. Review of the facility's documentation revealed staff had taken a post test after the education and signed an acknowledgement form. Continued review of the documentation revealed staff attendance signatures which indicated they had received the abuse inservice on 03/05/14 and 03/06/14. Further review of the inservice education sign-in sheets revealed dietary, housekeeping, nurses, SRNAs, office staff, activities, SS, medical records, laundry and therapy staff had received the education. Additionally, review revealed staff who had not received the education on 03/05/14 and 03/06/14 were inserviced prior to returning to work on 03/07/14 through 03/13/14. Interview with the Staff Development Nurse on 03/13/14 at 2:05 PM, revealed she had a master list of staff with signatures of everyone who had been inserviced; and she had inserviced everyone who had worked so far. The Staff Development Nurse stated the facility had some "PRN" (as needed) staff who had not worked since 03/05/14; and she would inservice those staff before they worked. According to the Staff Development Nurse, the staff abuse inservice covered types of abuse, protecting residents, immediately reporting abuse; and to who and when to report suspected abuse. Interviews on 03/12/14 with SRNA #8 at 3:20 PM; SRNA #6 at 5:10 PM; SRNA #10 at 5:15 PM; SRNA # 9 at 5:56 PM; SRNA #11 at 5:25 PM; LPN #5 at 3:44 PM; LPN #12/Unit Coordinator East Wing at 4:30 PM; LPN #6 at 4:50 PM; LPN # 10 at 4:53 PM; LPN #8 at 4:55 PM; LPN #7 at 5:50 PM; RN #2/Unit Manager West Wing at 5:35 PM; Activity Director at 3:45 PM; Activity Assistant at 4:05 PM; Housekeeping Supervisor at 4:15 PM; Laundry Personnel #1 at 4:20 PM; Laundry Personnel #2 at 6:10 PM; Director of Dietary 4:25 PM; Dietary Aide #1 at 4:30 PM; PM Cook at 4:32 PM; Administrative Assistant at 5:10 PM; Bookkeeper at 5:15 PM; and Maintenance Director at 5:40 PM revealed they all had been in-serviced on types of abuse, suspecting abuse, protecting residents and immediately reporting abuse; and to whom to report abuse. Interviews on 03/13/14 with SRNA #15 at 9:00 AM; SRNA #12 at 9:29 AM; SRNA #13 at 9:36 PM; SRNA #17 at 9:46 PM; SRNA #14 at 10:06 AM; SRNA #1 at 10:34 AM; SRNA #5 at 12:23 PM; SRNA #16 at 12:35 PM; SRNA #2 at 1:23 PM; LPN # 11/House Supervisor at 8:50 AM; LPN #13 at 10:55 AM; LPN #12 at 10:26 AM; LPN #4 at 2:24 PM; LPN #14/Quality Assurance Nurse at 2:54 PM; RN #4 at 8:43 PM; RN #5 at 9:56 PM; RN #6 at 11:08 PM; Maintenance Assistance at 9:05 AM; Laundry Personnel #3 at 9:15 AM; Speech Therapist at 10:20 AM; Floor Tech at 10:30 AM; Housekeeping Personnel #1 at 10:45 AM; Business Office Manager at 10:50 AM; and MDS Coordinator at 12:00 PM revealed they all had been in-serviced on types of abuse, suspecting abuse, protecting residents and immediately reporting abuse; and to whom to report abuse. 3. Record review revealed a weekly skin assessment was completed on 02/22/14 for Resident #1; which had no documented suspicious bruising or marks that might have indicated physical abuse. Record review revealed routine skin assessments had been completed on 02/21/14 to 02/27/14, for all residents cared for by SRNA #1 on 02/20/14 and 02/21/14, with no documented evidence of suspicious bruising or signs of potential physical abuse noted. 4. The facility's re-investigation was reviewed and revealed interviews had been conducted with Resident #12 and Resident #15, and other cognitively intact residents and had revealed no complaints of verbal abuse by SRNA #1. In addition, Resident #1's roommate/sister had been interviewed by the facility and denied any abuse by staff of herself or Resident #1. Interviews on 03/12/14 with Resident #12, Resident #15, Unsampled Resident I, who was Resident #1's roommate/sister, and other cognitively intact residents verified they had been interviewed by facility staff in regards to any staff abuse. Interview with the Administrator on 03/12/14 at 5:27 PM, and the DON on 03/13/14 at 11:30 AM, revealed they had obtained statements from the residents who had been involved in the allegations; and from other interviewable residents who had been cared for by SRNA #1. The DON and Administrator both stated the facility had not been able to substantiate any of the abuse allegations. 5. Interview with the SS Director on 03/12/14 at 4:29 PM, with the Administrator on 03/12/14 at 5:27 PM, and with the DON on 03/13/14 at 11:30 AM revealed allegations of abuse were to be reviewed by the investigation team and investigations were to be started immediately during normal business hours and the tasks would be delegated. The interviews revealed during off hours staff was to notify the supervisor who would contact the Administrator, SS Director or DON; and they would direct the supervisor on the investigation, and a member of the investigation team would come in. The Administrator stated the findings of the facility's investigation would be reported to the Nurse Consultant during the investigation, and as soon as the investigation was completed for her review. Further interview with the Administrator revealed he, or in his absence the DON, SS Director or designee, would do the reporting to the required authorities within the required time frames. Interview with the Nurse Consultant on 03/12/14 at 5:45 PM, revealed the facility's investigation team would complete the allegation of abuse investigations, and the Nurse Consultant would be notified of the findings. The Nurse Consultant stated he/she would review the facility's investigation to ensure initial reporting had occurred and to ensure the investigation had been completed within the five (5) day time frame for reporting to the State Agency. 6. Review of the facility's CQI Indicator for Abuse Reporting and Investigation tool revealed the components of the abuse regulations were included in the tool; and the tool had a threshold goal of 100%. In addition, the Evaluation of CQI Program tool used to determine if the CQI Indicator tool outcome had been successful or if corrective actions were needed was also reviewed. Interviews with the Administrator on 03/12/14 at 5:27 PM and the DON on 03/13/14 at 11:30 AM, verified the facility would utilize the CQI Indicator tool when conducting the abuse investigations at a minimum weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter as per the AOC. The CQI Indicator tool would be utilized for a longer period of time if necessary which would be determined by the QA Committee. The interviews with the DON and Administrator revealed the CQI tool would take them through the abuse protocol steps; and at the end of the investigation it would help them make sure they had taken the appropriate actions. The Administrator stated the CQI team would supervise the CQI monitor; however he was ultimately responsible. The Administrator stated during abuse investigations the CQI tool results would be presented to the QA team at the daily meetings Monday through Friday; and to the QA Committee monthly. He stated if the established threshold of 100% was not met, they would determine what had gone wrong and set up a plan of correction. In addition, the Administrator stated the completed CQI tool would be reviewed by the Nurse Consultant monthly to determine that allegations were investigated and reported appropriately and that thresholds were met. Interview, on 03/13/14 at 1:54 PM, with the QA Nurse verified the CQI tool for abuse results would be reported to the QA Committee at the monthly meetings. In addition, she stated if the CQI indicator did not meet the threshold they would analyze why it had not met the threshold; and put together an action plan to resolve the area of concern. 7. Review of the 03/06/14 QA Committee Meeting Minutes, no time noted, revealed the QA team had communicated with the Medical Director via phone call and discussed the two (2) allegations of verbal abuse, and one (1) allegation of physical abuse which had occurred on 02/20/14. Continued review revealed the Medical Director was informed the allegations were not reported by the SRNA until 02/25/14 because the SRNA could not find a nurse to report the allegations to. In addition, review of the meeting minutes revealed the QA team and Medical Director discussed what the facility had done to ensure the safety of all residents, and had started the abuse investigation process. Interviews with the Administrator on 03/12/14 at 5:27 PM and with the DON on 03/13/14 at 11:30 AM revealed the Medical Director was contacted on 03/06/14 regarding the abuse allegations, interviews, what the facility had put in place and the reporting of the abuse. Interview, on 03/08/14 at 11:30 AM, with the Medical Director revealed he was made aware of the Immediate Jeopardy (IJ) situation at the facility on 03/06/14. He stated the facility had discussed with him what had occurred; what the facility had done so far; and what they would be implementing. 8. Interview, on 03/12/14 at 5:45 PM, with the Nurse Consultant verified the Nurse Consultant would conduct an evaluation of the facility's CQI program on the monthly visits for three (3) months, then annually thereafter. According to the Nurse Consultant the results would be reported to the QA Committee.

Based on interview and record review it was determined the facility failed to maintain a Quality Assessment and Assurance (QA) Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies in regards to failure to ensure abuse polices were implemented for three (3) of twenty-one (21)sampled residents (Resident #1, #12 and #15). The facility failed to ensure allegations of verbal abuse of Resident #12 and Resident #15; and an allegation of physical abuse of Resident #1 had been reported immediately to the Administrator and to the State Agencies in accordance with State law. In addition, the facility failed to ensure all these alleged violations were fully investigated; and failed to protect residents in order to prevent further potential abuse while the investigation was in progress. (Refer to F-225, F-226, and F-490). The facility's failure to ensure the Quality Assessment and Assurance (QA) Program developed and implemented appropriate plans of action to correct quality deficiencies was likely to cause risk for serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 03/05/14, and determined to exist on 02/20/14. The facility was notified of the Immediate Jeopardy on 03/05/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 03/12/14 with the facility alleging removal of the Immediate Jeopardy on 03/07/14. The Immediate Jeopardy was verified to be removed on 03/07/14, prior to exiting the facility on 03/13/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-520, with a Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. In addition, the facility failed to maintain a Quality Assessment and Assurance (QA) Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies in regards to the facility's infection control program. The findings include: Review of the Quality Assurance (QA) Program Policy, undated, revealed the QA Program was designed to identify, develop, plan, implement, monitor and ensure correction of deviations from quality. Further review revealed the QA Committee was comprised of the Director of Nursing (DON), Administrator, Medical Director and at least three (3) other members of the facility's staff, and was to meet at least quarterly. 1. Review of the Plan of Correction (POC) dated and signed by the previous Administrator on 06/04/13, with a compliance date of 04/26/13, revealed all staff was inserviced on abuse and the facility's abuse policy, including, but not limited to: identification, protection of residents and reporting of abuse on 04/12/13 through 04/16/13. All nurse supervisors and administrative nurses received inservice education on the investigation and reporting of abuse as provided by the DON and Assistant Director of Nursing (ADON) on 04/16/13, including but not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations of findings. Continued review of the POC revealed all allegations were to be reviewed by the facility's investigation team, Administrator, Social Service (SS) Director, DON and ADON, to determine which team members would investigate and report the allegation to the required authorities seven (7) days a week. The POC stated the Administrator would complete an allegation check list detailing the required steps of the investigation process from beginning to end to step the investigator through all aspects. If the Administrator was unavailable, the DON or SS Director would complete the checklist. The POC stated the Administrator was to complete an allegation checklist audit for 100% of the allegations made and investigated. The Continuous Quality Improvement (CQI) Indicator for the monitoring of compliance with the components of the abuse regulation would be utilized weekly for four (4) weeks, then monthly thereafter under the supervision of the Administrator. The findings of the completed allegation checklists and CQI indicators would be reviewed by the corporate contracted Nurse Consultant with monthly visits. On 02/25/14 at approximately 10:30 PM, the House Supervisor, Registered Nurse (RN) #1, was notified by State Registered Nursing Assistant (SRNA) #2, of another SRNA, (SRNA #1) having been verbally abusive to Resident #15 and Resident #12; and physically abusive to Resident #1 on 02/20/14 (five days earlier). However, there was no documented evidence the facility began an investigation until 02/27/14, two (2) days after the Administration became aware of the allegations. Review of the investigation form and interviews revealed the investigation of the alleged abuse consisted of interviewing Resident #12 and Resident #15 on 02/27/14; other interviewable residents were not interviewed until 03/03/14. In addition, the staff who worked at the time of the alleged events, including the alleged perpetrator, SRNA #1 was not interviewed when the facility was notified of the abuse allegations. Also, although Administration became aware of the allegations on 02/25/14, the State Agencies were not notified of the verbal abuse allegations until 02/28/14; and were not notified of the physical abuse allegation until 03/05/14. Additionally, Administration became aware of the abuse allegations on 02/25/14; however, the alleged perpetrator worked on 02/26/14 from 3:00 PM to 3:30 PM, prior to being suspended that day by the Administrator. (Refer to F-225, F-226 and F490). Interview on 03/07/14 at 12:50 PM with the Director of Nursing revealed the facility reviewed each allegation of abuse daily in the morning Continuous Quality Improvement (CQI) meeting and the Interdisciplinary Plan of Care (IPOC) meeting which included the DON, Minimum Data Set (MDS) Nurses, Social Services (SS), Unit Managers and the Administrator. The DON stated, in the meeting, it was decided who would investigate and report the allegations. She stated the DON, SS, and Administrator all worked as a team on the investigations. Continued interview revealed she completed the allegation checklist for each abuse allegation; however she did not complete the CQI Indicator and did not know if this was still being performed by anyone. The DON called the SS Director during the interview and the SS Director informed the DON she had not been completing the CQI Indicator. The DON stated the Nurse Consultant had been notified of the current allegations on 02/27/14 verbally; however, the Nurse Consultant had not reviewed the facility's investigation. Interview on 03/07/14 at 12:50 PM with the QA Nurse, revealed the facility discussed any allegations of abuse in QA; however she indicated she had been unable to find any CQI Indicators completed on abuse since 09/27/13. She stated the facility had two (2) new administrators since November 2013. Interview, on 03/11/14 at 1:14 PM and 03/13/14, with the Administrator revealed he had started his employment at the facility on 12/17/13. He stated he had attended one (1) QA meeting in December 2013; and they had gone over abuse allegations in that meeting. He stated all abuse investigations were still being looked at by the DON, SS, and himself; but the DON took the lead on the investigations and had been completing the allegation checklists since he had been the Administrator. The Administrator stated he had reviewed the current allegation checklist and noted the State Agencies had not been notified timely. He stated the staff members involved should have been interviewed early on; however, after the interviewable residents said nothing happened, he had not felt it was necessary to interview staff. According to the Administrator, the Nurse Consultant had reviewed the facility's investigation related to these allegations and had not notified the facility of any problems with the investigation. Review of the abuse allegations since December 2013, revealed there had been two (2) misappropriation allegations; and, two (2) abuse allegations and the allegation check list had been completed. However, there was no documented evidence the CQI Indicator had been completed for the four (4) allegations. The Administrator stated, although the abuse allegations were being discussed in the QA meetings, and the allegation checklists completed; the CQI Indicator had not been utilized as per the former POC. Interview, on 03/08/14 at 11:30 AM with the Medical Director, revealed he attended the facility's QA meetings monthly and the facility had made him aware of the allegations and Immediate Jeopardy. He stated, after the facility had been cited in April 2013 with Immediate Jeopardy related to abuse, the facility had to ensure all allegations of abuse were thoroughly investigated to include interviewing residents and staff. The Medical Director stated the thorough investigation should include evaluating subjective and objective data, corroborating the information received, and creating an action plan. According to the Medical Director, staff was to immediately report allegations of abuse. He stated the State Agencies were to be notified of abuse allegations within twenty-four (24) hours. The Medical Director indicated when Administration had been notified of the allegations, they should have immediately started the investigation and not allowed SRNA #1 to work. 2. Review of the facility's POC, with a compliance date of 05/06/13, revealed nursing staff received in-service education on provision of resident care, including skin assessments, to include hand washing and changing of gloves in accordance with infection control standards of practice. Further review revealed monitoring for handwashing and glove changing during care were to continue monthly for two (2) months and then every six (6) months thereafter. Observation during the current survey of Resident #6's skin assessment, revealed the nurse assessed the resident's buttock area touching the buttocks; and then without washing or sanitizing her hands and changing her gloves, assessed the resident's vaginal/perineal area. Interview, on 03/06/14 at 5:54 PM and on 03/11/14 2 PM, with the QA/Infection Control (IC) Nurse revealed the nurse should have assessed the resident's perineal/vaginal area first; and then the buttock area to prevent cross contamination. She stated there were two (2) CQI audits performed for general infection control which had been done on 10/11/13; however, these audits had not included observation of skin assessments. She indicated however, the observation of skin assessments had still been done every six (6) months; and three (3) observations of skin assessments were done in November 2013. Interview with the DON, on 03/08/14 at 2:22 PM, revealed she indicated the issues identified with handwashing and skin assessments were infection control issues because of the possibility of transferring potentially harmful organisms. She further stated the facility had not had ongoing audits of handwashing and the current role of the ICN had been to track and trend infections only. The facility provided an acceptable credible Allegation of Compliance (AOC), on 03/12/14 which alleged removal of the Immediate Jeopardy on 03/07/14. Review of the AOC revealed the facility implemented the following: 1. The investigation was reopened on 03/05/14. Residents #12 and #15 were re-interviewed with additional questions by the DON, Administrator and/or Social Services (SS) Director on 03/06/14. Resident #1's roommate, which was the resident's sister was interviewed on 03/06/14, by the DON because Resident #1 was not interviewable. During the resident interviews on 03/06/14, no complaints or allegations against State Registered Nursing Assistant (SRNA) #1 were received. Other residents under the care of SRNA #1 with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were also interviewed from 03/01/14 to 03/06/14 by the DON, Administrator and/or SS Director with no complaints noted. All the staff working on the same hall as SRNA #1 the evening the alleged abuse occurred were interviewed by the DON, Administrator or SS Director on 03/06/14 and no complaints or concerns were verbalized. 2. SRNA #2 was counseled by the DON immediately via phone on 02/25/14, and in writing on 02/28/14, regarding compliance with the facility's Abuse Policy; and the requirement of immediately reporting all suspected abuse. The DON received education by the Nurse Consultant on 03/05/14 regarding the regulatory requirements on reporting and investigating abuse. The DON, Administrator and SS Director received in-service education by the Nurse Consultant on investigation and reporting of abuse on 03/06/14. The re-education included, but was not limited to: identification of events requiring investigation; protecting residents; interviewing residents, staff and all witnesses; and timely reporting of allegations and findings. All facility staff licensed and unlicensed received in-service education on abuse and on the facility's abuse policy, which included: immediately reporting any suspected abuse, neglect, exploitation or misappropriation; and protecting residents. The re-education was provided by the DON, Administrator and SS Director on 03/05/14 through 03/06/14. Any staff on leave, vacation, or unavailable for the in-service would not be able to clock in or work until completing the in-service education. The facility does not utilize agency staffing. 3. A weekly skin assessment performed by the Charge Nurse on 02/22/14, for Resident #1 revealed no suspicious bruising or marks which would indicate physical abuse. Routine skin assessments performed 02/21/14 through 02/27/14, by the Charge Nurses on duty, revealed no suspicious bruising or signs of potential physical abuse of the residents who might have received care by SRNA #1, 02/20/14 through 02/21/14 or any other employee. 4. The investigation was concluded on 03/06/14 with the findings unsubstantiated based on the interviews with Resident #12 and Resident #15 and other cognitively intact residents which revealed no verbal abuse by SRNA #1. Resident #1's roommate/sister had been interviewed and denied any abuse by staff. 5. All reported allegations were to be reviewed by the facility's investigation team including the Administrator, SS Director and DON immediately during normal business hours to determine which team members would investigate, and report the allegation to the required authorities. During off hours, staff was to notify the DON and/or Administrator immediately via phone; and the DON and/or Administrator would determine who should investigate and report. The Administrator was to report all findings of the facility's investigation team to the Nurse Consultant upon conclusion of the team review, within five (5) working days of the allegation, to determine that all necessary investigation and reporting interventions had been initiated. 6. The Continuous Quality Improvement (CQI) indicator for the monitoring for compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, was to be utilized with each allegation of abuse weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter under the supervision of the Administrator. Results of each abuse allegation CQI indicator was to be presented by the DON, Administrator or SS Director or designee; and reviewed with the QA team as part of the daily meetings Monday through Friday. Failure to meet the established threshold of one hundred percent (100 %) on the CQI indicator tool would result in intervention; and an immediate internal plan of correction to address the identified areas of concern. The findings of the completed CQI indicators were to be reviewed by the contracted Nurse Consultant with monthly visits, to determine that allegations were investigated and reported as indicated. The effectiveness of the facility's administration would be monitored through the CQI process. Results were to be reported to the QA Committee by the Administrator, DON, SS Director or designee. 7. The facility's QA team with the Medical Director convened on 03/06/14 to review the circumstances of the allegations, and all interventions which had been and were to be implemented by the facility. 8. The Contracted Nursing Consultant and or Nursing Home Administrator (NHA) consultant will conduct an evaluation of the facility's CQI program monthly for three (3) months, then annually thereafter. Results will be reported to the QA committee. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's documentation revealed the investigation had been re-opened. Review revealed Resident #12 and Resident #15 were re-interviewed on 03/06/14 by the SS Director with additional specific questions and no concerns identified. Review of the documentation revealed Resident #1's roommate/sister had been re-interviewed on 03/06/14 by the SS Director with no concerns noted. Additionally, review revealed seventeen (17) other residents with a BIMS of eight (8) or above had been interviewed between 03/01/14 and 03/06/14 with no concerns identified. Further review revealed all staff members who had worked the West Wing evening shift on 02/20/14, where SRNA #1 allegedly abused residents, were interviewed and had signed Witness Statements, dated 03/06/14. 2. Review of the "Improvement Plan" dated 02/26/14, revealed SRNA #2 had been counseled for not reporting concerns to the supervisor immediately in regards to verbal remarks from another SRNA; and for not following facility policy related to abuse. The Plan was marked as "first counseling" and signed by the DON on 02/28/14. Continued review revealed the DON had attempted to provide a written counseling with SRNA #2 on 02/28/14; however the employee refused to sign it. Interview with the DON on 03/13/14 at 2:20 PM, revealed she had talked to SRNA #2 about abuse on 02/28/14 and attempted to have her sign a written counseling; however SRNA #2 had refused to sign it. Review of a sign-in sheet dated 03/06/14, revealed the Administrator, DON and SS Director had attended the Nurse Consultant's inservice on abuse. Interview with the DON on 03/13/14 at 11:30 AM revealed she had received an inservice from the Nurse Consultant on 03/05/14 and 03/06/14 via phone conference call. She stated the Nurse Consultant educated her on abuse, investigation of abuse, getting statements from residents and staff related to the incident; and regulatory requirements. She stated the Nurse Consultant had also talked about events which would require investigation, types of abuse, how to suspect abuse, protecting residents, and reporting abuse to State Agencies. Interview with the Administrator on 03/12/14 at 5:27 PM, and the SS Director on 03/12/14 at 4:29 PM, revealed they had a conference with the Nurse Consultant on 03/06/14; and were educated on identifying abuse, the different types of abuse, what needed to be investigated, interviewing all the staff working with the residents, interviewing residents, having staff turn in a written statement related to the abuse, reporting abuse and time frames for reporting abuse. Interview with the Nurse Consultant on 03/13/14 at 9:30 AM, revealed she had given training to the Administrator, SS Director and DON on 03/06/14. She further stated the training on abuse had included identification, documentation, conducting interviews, investigation, and timely reporting requirements of abuse. Review of the facility's inservice education related to abuse revealed it had included the policies on abuse, reporting and investigating abuse, examples of abuse. Review of the facility's documentation revealed staff had taken a post test after the education and signed an acknowledgement form. Continued review of the documentation revealed staff attendance signatures which indicated they had received the abuse inservice on 03/05/14 and 03/06/14. Further review of the inservice education sign-in sheets revealed dietary, housekeeping, nurses, SRNAs, office staff, activities, SS, medical records, laundry and therapy staff had received the education. Additionally, review revealed staff who had not received the education on 03/05/14 and 03/06/14 were inserviced prior to returning to work on 03/07/14 through 03/13/14. Interview with the Staff Development Nurse on 03/13/14 at 2:05 PM, revealed she had a master list of staff with signatures of everyone who had been inserviced; and she had inserviced everyone who had worked so far. The Staff Development Nurse stated the facility had some "PRN" (as needed) staff who had not worked since 03/05/14; and she would inservice those staff before they worked. According to the Staff Development Nurse, the staff abuse inservice covered types of abuse, protecting residents, immediately reporting abuse; and to who and when to report suspected abuse. Interviews on 03/12/14 with SRNA #8 at 3:20 PM; SRNA #6 at 5:10 PM; SRNA #10 at 5:15 PM; SRNA # 9 at 5:56 PM; SRNA #11 at 5:25 PM; LPN #5 at 3:44 PM; LPN #12/Unit Coordinator East Wing at 4:30 PM; LPN #6 at 4:50 PM; LPN # 10 at 4:53 PM; LPN #8 at 4:55 PM; LPN #7 at 5:50 PM; RN #2/Unit Manager West Wing at 5:35 PM; Activity Director at 3:45 PM; Activity Assistant at 4:05 PM; Housekeeping Supervisor at 4:15 PM; Laundry Personnel #1 at 4:20 PM; Laundry Personnel #2 at 6:10 PM; Director of Dietary 4:25 PM; Dietary Aide #1 at 4:30 PM; PM Cook at 4:32 PM; Administrative Assistant at 5:10 PM; Bookkeeper at 5:15 PM; and Maintenance Director at 5:40 PM revealed they all had been in-serviced on types of abuse, suspecting abuse, protecting residents and immediately reporting abuse; and to whom to report abuse. Interviews on 03/13/14 with SRNA #15 at 9:00 AM; SRNA #12 at 9:29 AM; SRNA #13 at 9:36 PM; SRNA #17 at 9:46 PM; SRNA #14 at 10:06 AM; SRNA #1 at 10:34 AM; SRNA #5 at 12:23 PM; SRNA #16 at 12:35 PM; SRNA #2 at 1:23 PM; LPN # 11/House Supervisor at 8:50 AM; LPN #13 at 10:55 AM; LPN #12 at 10:26 AM; LPN #4 at 2:24 PM; LPN #14/Quality Assurance Nurse at 2:54 PM; RN #4 at 8:43 PM; RN #5 at 9:56 PM; RN #6 at 11:08 PM; Maintenance Assistance at 9:05 AM; Laundry Personnel #3 at 9:15 AM; Speech Therapist at 10:20 AM; Floor Tech at 10:30 AM; Housekeeping Personnel #1 at 10:45 AM; Business Office Manager at 10:50 AM; and MDS Coordinator at 12:00 PM revealed they all had been in-serviced on types of abuse, suspecting abuse, protecting residents and immediately reporting abuse; and to whom to report abuse. 3. Record review revealed a weekly skin assessment was completed on 02/22/14 for Resident #1; which had no documented suspicious bruising or marks that might have indicated physical abuse. Record review revealed routine skin assessments had been completed on 02/21/14 to 02/27/14, for all residents cared for by SRNA #1 on 02/20/14 and 02/21/14, with no documented evidence of suspicious bruising or signs of potential physical abuse noted. 4. The facility's re-investigation was reviewed and revealed interviews had been conducted with Resident #12 and Resident #15, and other cognitively intact residents and had revealed no complaints of verbal abuse by SRNA #1. In addition, Resident #1's roommate/sister had been interviewed by the facility and denied any abuse by staff of herself or Resident #1. Interviews on 03/12/14 with Resident #12, Resident #15, Unsampled Resident I, who was Resident #1's roommate/sister, and other cognitively intact residents verified they had been interviewed by facility staff in regards to any staff abuse. Interview with the Administrator on 03/12/14 at 5:27 PM, and the DON on 03/13/14 at 11:30 AM, revealed they had obtained statements from the residents who had been involved in the allegations; and from other interviewable residents who had been cared for by SRNA #1. The DON and Administrator both stated the facility had not been able to substantiate any of the abuse allegations. 5. Interview with the SS Director on 03/12/14 at 4:29 PM, with the Administrator on 03/12/14 at 5:27 PM, and with the DON on 03/13/14 at 11:30 AM revealed allegations of abuse were to be reviewed by the investigation team and investigations were to be started immediately during normal business hours and the tasks would be delegated. The interviews revealed during off hours staff was to notify the supervisor who would contact the Administrator, SS Director or DON; and they would direct the supervisor on the investigation, and a member of the investigation team would come in. The Administrator stated the findings of the facility's investigation would be reported to the Nurse Consultant during the investigation, and as soon as the investigation was completed for her review. Further interview with the Administrator revealed he, or in his absence the DON, SS Director or designee, would do the reporting to the required authorities within the required time frames. Interview with the Nurse Consultant on 03/12/14 at 5:45 PM, revealed the facility's investigation team would complete the allegation of abuse investigations, and the Nurse Consultant would be notified of the findings. The Nurse Consultant stated he/she would review the facility's investigation to ensure initial reporting had occurred and to ensure the investigation had been completed within the five (5) day time frame for reporting to the State Agency. 6. Review of the facility's CQI Indicator for Abuse Reporting and Investigation tool revealed the components of the abuse regulations were included in the tool; and the tool had a threshold goal of 100%. In addition, the Evaluation of CQI Program tool used to determine if the CQI Indicator tool outcome had been successful or if corrective actions were needed was also reviewed. Interviews with the Administrator on 03/12/14 at 5:27 PM and the DON on 03/13/14 at 11:30 AM, verified the facility would utilize the CQI Indicator tool when conducting the abuse investigations at a minimum weekly for four (4) weeks, then monthly for four (4) months and then quarterly thereafter as per the AOC. The CQI Indicator tool would be utilized for a longer period of time if necessary which would be determined by the QA Committee. The interviews with the DON and Administrator revealed the CQI tool would take them through the abuse protocol steps; and at the end of the investigation it would help them make sure they had taken the appropriate actions. The Administrator stated the CQI team would supervise the CQI monitor; however he was ultimately responsible. The Administrator stated during abuse investigations the CQI tool results would be presented to the QA team at the daily meetings Monday through Friday; and to the QA Committee monthly. He stated if the established threshold of 100% was not met, they would determine what had gone wrong and set up a plan of correction. In addition, the Administrator stated the completed CQI tool would be reviewed by the Nurse Consultant monthly to determine that allegations were investigated and reported appropriately and that thresholds were met. Interview, on 03/13/14 at 1:54 PM, with the QA Nurse verified the CQI tool for abuse results would be reported to the QA Committee at the monthly meetings. In addition, she stated if the CQI indicator did not meet the threshold they would analyze why it had not met the threshold; and put together an action plan to resolve the area of concern. 7. Review of the 03/06/14 QA Committee Meeting Minutes, no time noted, revealed the QA team had communicated with the Medical Director via phone call and discussed the two (2) allegations of verbal abuse, and one (1) allegation of physical abuse which had occurred on 02/20/14. Continued review revealed the Medical Director was informed the allegations were not reported by the SRNA until 02/25/14 because the SRNA could not find a nurse to report the allegations to. In addition, review of the meeting minutes revealed the QA team and Medical Director discussed what the facility had done to ensure the safety of all residents, and had started the abuse investigation process. Interviews with the Administrator on 03/12/14 at 5:27 PM and with the DON on 03/13/14 at 11:30 AM revealed the Medical Director was contacted on 03/06/14 regarding the abuse allegations, interviews, what the facility had put in place and the reporting of the abuse. Interview, on 03/08/14 at 11:30 AM, with the Medical Director revealed he was made aware of the Immediate Jeopardy (IJ) situation at the facility on 03/06/14. He stated the facility had discussed with him what had occurred; what the facility had done so far; and what they would be implementing. 8. Interview, on 03/12/14 at 5:45 PM, with the Nurse Consultant verified the Nurse Consultant would conduct an evaluation of the facility's CQI program on the monthly visits for three (3) months, then annually thereafter. According to the Nurse Consultant the results would be reported to the QA Committee.

Based on observation. interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure each resident was free from sexual abuse for two (2) of five (5) sampled residents (Resident #1 and Resident #2). On 01/25/13, the facility received an allegation of abuse from Resident #2, who reported State Registered Nurse Aide (SRNA) #1 got in his/her bed and straddled him/her. Two (2) Social Workers (SW) interviewed Resident #2 and gave written accounts of their conversations with the resident. During interview with SW #1, and upon review of the written statements, it was revealed both SWs reported Resident #2 referred to a leaking water heater over his/her head that needed to be fixed immediately, as evidence Resident #2 had hallucinations. Interviews with Administrative Staff revealed they determined, based on the SW interviews, the resident's confusion and changing of the story, and SRNA #1's adamant denial of the incident, there was not a credible allegation of abuse to be thoroughly investigated or reported. SRNA #1 was allowed to continue working in an unrestricted manner. No further documented evidence related to an investigation was provided. On 04/12/13, at approximately 2:45 AM, Registered Nurse (RN) #1 entered the room of Resident #1. She observed Resident #1 to be lying sideways on the bed, and SRNA #1 was standing between Resident #1's open legs. During interview, RN #1 revealed SRNA #1 immediately began adjusting his pants and moved away from Resident #1. RN #1 stated she turned on the light and noted SRNA #1 had an erection which was clearly visible through his pants, and his belt was open with the ends of the belt hanging down on both sides. Interview with the investigating detective revealed SRNA #1 was arrested and charged under the Elder Justice Act, which prohibits abuse, and a criminal investigation was ongoing. Based on the findings, the facility's failure to protect residents for abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 04/15/13 and was determined to exist on 01/25/13. The facility was notified of the Immediate Jeopardy on 04/15/13. The facility provided an acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) on 04/23/13, with the facility alleging the IJ had been removed on 04/18/13. On 04/24/13, the State Survey Agency verified the IJ was removed on 04/18/13 as alleged, with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-223 at a Scope and Severity (S/S) of a "D" while the facility develops and implements its Plan of Correction and the facility's Quality Assurance Program continues to monitor and ensure residents are protected from abuse. The findings include: Review of the facility's policy titled "Policy on Abuse", undated, revealed sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Continued review revealed the facility would actively promote the absence of abuse from all individuals. 1. Review of the clinical record revealed the facility admitted Resident #2 on 05/31/04 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, completed by the facility on 12/28/12, revealed Resident #2 scored ten (10) of a possible fifteen (15) in cognition, indicating the resident was moderately impaired in cognitive skills. Review of Section D of the Quarterly MDS Assessment related to Mood revealed Resident #2 had trouble concentrating on things, but was assessed with [REDACTED]. Review of Section E0100 revealed Resident #2 exhibited no hallucinations and no [MEDICAL CONDITION] during the assessment period. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed Resident #2 alleged, a few months ago (01/25/13), SRNA #1 had straddled him/her in the bed. She stated two Social Workers (SW) went immediately to interview the resident, who then denied the allegation. The Administrator stated Resident #2 had a history of [REDACTED]. She stated the facility declined to conduct a formal investigation. During interview, on 04/12/13 at 5:05 PM, Resident #2 stated "it was at least a couple of weeks ago" that SRNA #1 got in his/her bed and straddled him/her, with one leg on each side. The resident reported that he/she told SRNA #1, "you better get off me", and he did. Resident #2 further stated he/she reported the incident when it occurred, but could not say who he/she reported to, and did not recall anything about an investigation. Review of the written statement of SW #1, dated 01/25/13, revealed Resident #2 stated SRNA #1 did not get in his/her bed, but "he wanted to and I told him to get the hell out of here". Review of the written statement by SW #2, also dated 01/25/13, revealed Resident #2, in reference to SRNA #1, stated "he thinks he's sexy and tried to get in bed with me, but I kicked him away". Both statements indicated Resident #2 exhibited hallucinations about a leaky water heater on the ceiling. Interview with SW #1, on 04/15/13 at 3:40 PM, revealed SW #2 was no longer employed at the facility. SW #1 stated Resident #2 denied SRNA #1 had gotten in his/her bed. She further stated she and SW #2 felt Resident #2 was confused and delusional. Therefore, they determined Resident #2 had not made a credible allegation. Interview with the Director of Nursing (DON) and the MDS Nurse, on 04/15/13 at 4:00 PM, revealed the MDS Nurse was House Supervisor (HS) at the time of Resident #2's allegation regarding SRNA #1. Continued interview revealed the DON and the HS had interviewed SRNA #1 on 01/25/13 after hearing of the allegation against him. The DON and the HS concurred SRNA #1 was very defensive and indignant during the interview, and adamantly denied any inappropriate comments or behaviors while providing care to Resident #2. They stated SRNA #1 seemed "very sincere". The DON and the HS both stated that based on the resident's confusion by history, no observations of anything inappropriate by (SRNA #1), his adamant denial, and the resident changing his/her story, they felt it was not a credible allegation. During follow-up interview, on 04/15/13 at 3:05 PM, the Administrator stated two (2) Social Workers interviewed Resident #2 at different times. During both interviews, the resident denied SRNA #1 had gotten in his/her bed, and exhibited hallucinations when he/she became upset about a water heater that was not there. Based on the resident's confusion and hallucination about the water heater, and the resident changed his/her story, the Administrator concluded the allegation had no merit, i.e. was not credible, and no further investigation was warranted. However, review of the employee file for SRNA #1 revealed an employee conference was held on 01/25/13 and there was written counseling related to maintaining a professional approach with residents and treating all residents with respect during care giving. Further review revealed the DON documented SRNA #1 "denied inappropriate interactions with any residents and refused to sign". Review of the staffing schedule for January 2013 revealed SRNA #1 was working the night shift on 01/25/13 on the East Hall where Resident #2 resided. Continued review revealed SRNA #1 worked the 11-7 shift on the East Hall nearly every night, including 01/01/13 through 01/10/13, and 01/15/13 through 01/31/13. Continued review of the staffing schedule revealed SRNA #1 continued working regularly, up to and including the night shift of 04/12/13. 2. On 04/12/13, the State Agency received a facility reported incident of "possible sexual assault" when an employee was observed in a "compromising position" with Resident #1. Review of the clinical record revealed the facility admitted Resident #1 on 08/30/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/04/13, revealed the facility's assessment of the resident included a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of a possible fifteen (15), indicating the resident was cognitively intact and therefore interviewable. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed on 04/12/13 the House Supervisor (HS)/RN #1 working the night shift entered Resident #1's room and observed SRNA #1 with his belt unbuckled and an erection visible through his pants. She immediately sent SRNA #1 to the desk while she evaluated the situation to ensure Resident #1 was okay. Initially, the resident denied anything happened and denied any complaints. The HS/RN #1 left the room to find SRNA #1 and confirmed he had been seen going out of the facility, and a search of the parking lot revealed his car was gone. The HS/RN #1 went back to Resident #1's room with the Nurse assigned to his/her care Licensed Practical Nurse (LPN #2). At this time, the resident reported SRNA #1 was giving therapy "on my bottom". The resident further reported SRNA #1 gave him/her therapy about once a week. The Administrator was called at home, and she called 911 and came to the facility. The facility's investigation was initiated immediately and was ongoing. Review of the written statement provided by RN #1 after the incident, and interview with RN #1, on 04/17/13 at 9:15 AM, revealed she was working in the position of House Supervisor on the night shift of 04/12/13. During her routine rounds, at approximately 2:30 AM to 2:45 AM, she entered the room of Resident #1. The door was open, the curtain was pulled around the resident, and the light was off. The Nurse was not aware at that time anyone else was in the room. Without saying anything, she peeked around the curtain. Resident #1 was lying sideways with his/her bottom at the edge of the bed. His/her legs were bent at the hips and the knees, and the resident's knees were apart and up in the air. SRNA #1 was standing between Resident #1's legs in a crouching position, with his knees bent slightly and one hand on each of the resident's legs. As the Nurse pulled the curtain back, SRNA #1 looked up and saw the Nurse, stood up and began adjusting his pants. RN #1 was shocked and couldn't believe what she was seeing. She asked SRNA #1 if the resident was sliding out of the bed. SRNA #1 replied "yes" and began walking away. The Nurse turned the light on and observed SRNA #1 to have an erection clearly visible through his pants, and his belt was undone with the ends hanging down on either side. RN #1 instructed SRNA #1 to go to the desk. When he left the room, the Nurse began asking Resident #1 what happened. The resident was very calm, "emotionless", and reported nothing had happened. The resident had no complaints at that time. The Nurse went out to the Nurse's station where LPN #2 was sitting. She asked him where SRNA #1 was, and the LPN replied he walked past the desk in the direction of the exit door. A staff member (RN #1 could not remember who) went to the parking lot and verified SRNA #1's car was gone. RN #1 and LPN #2 went back to Resident #1's room to ensure the resident was okay, and try to determine what exactly had happened. On examination, the resident's perineal area appeared red and moist, but no lacerations, bruising or bleeding was noted. At this time, the resident stated he/she was "getting therapy in my bottom". The resident reported SRNA #1 provided the therapy "at least once a week". The resident also pointed to the left lower quadrant of his/her abdomen and stated it hurt. When RN #1 had ensured Resident #1 was not in acute physical or mental distress, she called the Director of Nursing (DON) at home and reported the incident. Ultimately, the Administrative team, the facility's Medical Director, local police, and Emergency Medical Services (EMS) responded to the facility. Resident #1 was transported to the Emergency Department (ED) at a local hospital for examination. Interview with LPN #2, on 04/16/13 at 3:47 PM, revealed he was the Nurse assigned to Resident #1 on the night shift of 04/12/13. He stated he was at the desk between 2:30 AM and 2:50 AM when SRNA #1 walked by, in the direction of the exit on the other side of the building. He stated he assumed SRNA #1 was going outside to smoke. He further stated within two (2) minutes, RN #1 approached the desk and stated SRNA #1 had to go home and reported she had observed him in a sexually inappropriate encounter with Resident #1. Continued interview revealed he went outside and saw SRNA #1's car was gone from the parking lot. On further interview, LPN #2 stated he went to check on Resident #1 with RN #1. He stated the resident pointed to the left lower quadrant of the abdomen and complained of pain. LPN #2 further reported Resident #1 stated SRNA #1 was giving him/her therapy and stated it had happened before, "about once a week". Review of the ED record for Resident #1 revealed the resident arrived on 04/12/13 at 4:35 AM, and was the reported victim of a sexual assault at the nursing home where he/she resided. Further review revealed the Sexual Assault Nurse Examiner (SANE) was in route to perform the physical examination. Continued review revealed all results of the examination, including any specimens collected, were turned over to law enforcement officials. Resident #1 was medically cleared and discharged back to the nursing home for follow up care. Observation, on 04/12/13 at 4:50 PM, revealed Resident #1 had been moved to a different room, as his/her previous room was considered a crime scene and a police investigation was ongoing. Resident #1 was sitting on the side of the bed and appeared clean and well-groomed, and was dressed appropriately in personal attire. The resident demonstrated a very flat affect, i.e. he/she exhibited no change in facial expression or tone of voice. During interview, on 04/12/13 at 4:50 PM, Resident #1 stated "I was raped last night". Resident #1 stated there was one other incident "a long time ago", he/she did not report the first incident and couldn't figure out how everybody found out this time. Resident #1 referred to SRNA #1 by name and stated, "he hurt me up inside". On further interview, Resident #1 expressed ambivalent feelings toward SRNA #1, e.g. "he was very kind", and "I was afraid of him". Resident #1 denied a clear memory of the day's events but stated it had been a very long day and he/she was very tired and "done talking about it". Interview with the sister of Resident #1, on 04/14/13 at 11:36 AM, revealed she was the resident's Power of Attorney (POA). She stated the facility called her about 3:00 AM on 04/12/13 and reported Resident #1 was the victim of a possible sexual assault. She further stated she and the resident's daughter went directly to the hospital Emergency Department and met Resident #1 there. On further interview, the POA stated the Sexual Assault Nurse Examiner (SANE) told her she examined the resident for evidence of sexual assault and found him/her to have a small tear and some blood. During continued interview, the POA stated she knew Resident #1 was swabbed "for semen and stuff" but the results weren't back yet. Interview with SRNA #3, on 04/18/13 at 10:40 AM, revealed she accompanied Resident #1 in the ambulance to the ED. She stated she remained with the resident throughout the stay and return trip to the facility. She further stated the resident did not speak of the incident in the ambulance; however, when the family arrived at the ED, Resident #1 told them SRNA #1 had raped him/her. Continued interview revealed SRNA #3 was present during the examination by the SANE Nurse. She stated she helped hold the resident's legs during the exam, and reported the resident appeared to be "ripped a little on the inside". Interview with the lead detective for the criminal investigation, on 04/15/13 at 1:40 PM, revealed he was in charge of the investigation and was still collecting information. During interview on 04/18/13 at 3:40 PM, the detective revealed SRNA #1 had been arrested under the Elder Justice Act, which prohibits abuse. He stated the investigation was ongoing; however, it would be several months before results of the forensic evidence analysis would be available. Interview with Physician #3, from the facility's contracted Psychiatric Services, on 04/16/13 at 3:20 PM, revealed he had evaluated Resident #1 earlier that day on 04/16/13. He stated the resident readily reported having been raped by SRNA #1. The resident stated it had happened twice. Physician #3 further stated Resident #1 exhibited a flat affect and increased sadness. He explained the resident was experiencing mixed emotions. Despite the rape, the resident was dealing with the loss of a friend, as SRNA #1 was kind and made him/her feel special. Follow-up interview with Resident #1, on 04/23/13 at 3:00 PM, revealed the resident had been "awful nervous", but no longer felt afraid and was glad SRNA #1 had been arrested. He/she stated SRNA #1 raped him/her twice, the first time was a long time ago. On further interview, Resident #1 stated SRNA #1 said he was giving therapy. The resident could not say what kind of therapy, "just therapy". The resident further stated "he shouldn't have done it". Interview with the Medical Director, on 04/16/13 at 3:10 PM, revealed he had been fully involved in the facility's response to the incident with Resident #1 on 04/12/13. Continued interview revealed he approached each resident and asked if they had any concerns with any staff acting inappropriately. He stated while talking to Resident #2 the resident reported someone, an employee, straddled him/her some time ago. The resident gave no other details except to say he/she told the perpetrator, "get off you SOB". The Physician declined to perform a physical exam, but reported the interview to the police and sent Resident #2 to the Emergency Department as well, in case there was any physical evidence to be obtained. On further interview, the Medical Director stated on thinking back, he recalled Resident #2 had made an allegation of some sort, but he had not interviewed him/her at that time. He stated he knew the facility did some sort of investigation and he recalled the facility felt Resident #2 was confused when the allegation was made, talked about a radiator, and was being treated for [REDACTED].?" Review of the facility's investigation summary, dated 04/16/13, revealed abuse was substantiated. The facility determined SRNA #1 was the perpetrator of sexual abuse and was terminated. The facility provided an acceptable AOC on 04/23/13 with an alleged removal of the IJ on 04/18/13. Review of the AOC by the State Survey Agency revealed the facility implemented the following actions: 1. The facility immediately initiated an investigation on 04/12/13 at 2:45 AM. The Police Department (PD), the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG, referred to as State Agency), and the Medical Director were notified. 2. Residents #1 and #2 were sent to the hospital for evaluation on 04/12/13. Both residents returned to the facility the same day and were offered follow-up counseling by the consultant Psychiatric Services and/or the Rape Crisis Center. 3. The identified staff member was removed immediately and sent a certified letter terminating his employment on 04/13/13. 4. All residents were interviewed by the Medical Director to determine if they had experienced any potential negative effects related to the allegation. All residents, except six (6) who refused, were physically examined by the Medical Director, beginning 04/12/13 and completed on 04/15/13. 5. The Social Services staff completed the PHQ9 interview, or the PHQ9-OV Assessment for mood/anxiety on 04/12/13. No resident had a score on the PHQ9 interview or the PHQ9-OV Assessment that indicated any mood or anxiety concerns. The facility was to repeat the interviews/assessments in one week and in two weeks, to evaluate for any delayed effects experienced by the residents. 6. The families and/or responsible parties for all residents were contacted and informed of the allegation. The Social Services staff, the Director of Nursing, and the Assistant Director of Nursing phoned each party beginning on 04/12/13. Any family and/or responsible party that could not be reached by phone by 04/16/13 was sent a certified letter on 04/17/13. 7. The facility employed a security officer for the night shift, beginning 04/13/13 and ongoing. In addition, increased staff on the night shift for added security, beginning 04/12/13. 8. All facility staff was inserviced on abuse and the facility's abuse policy, including, but not limited to: Identification, protection of residents, and reporting of abuse, as provided by the Staff Development Coordinator on 04/12/13 through 04/16/13. Any staff on leave, vacation, or unavailable for the inservice was locked out of the time clock, and will not be able to clock in or work until completing the inservice education. 9. All Nurse supervisors and administrative Nurses received inservice education on the investigation and reporting of abuse as provided by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 04/16/13, including but not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations and findings. 10. All allegations are to be reviewed seven (7) days per week by the facility's investigation team, consisting of the Administrator, the Social Service Director, the DON and the ADON, to determine which team members will investigate and report the allegation to the required authorities. 11. The facility's Quality Assurance Committee, with the Medical Director, met on 04/17/13 to review the circumstances of the allegation and all interventions which had been or would be implemented by the facility. 12. The CQI indicator for the monitoring of compliance with the components of the abuse regulation, including, but not limited to, investigating and reporting of abuse, are to be utilized with each allegation. The CQI indicator is to be used at least weekly for four (4) weeks, then monthly under the supervision of the Administrator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed she had called 911 immediately after receiving the report of the incident. She stated the PD responded immediately. Interview with the Lead Detective, on 04/15/13 at 1:40 PM, revealed he had assumed charge of the investigation on the morning of 04/12/13, from the night shift officer who responded to the 911 call. 2. A review of hospital records revealed Resident #1 and Resident #2 were evaluated in the ED and transferred back to the facility on [DATE]. Interview with Resident #2, on 04/23/13 at 2:50 PM revealed a lot of people had been talking to her, but she did not remember who. Interview with Resident #1, on 04/23/13 at 3:00 PM, revealed she had talked to the Rape Crisis Counselor. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed she had spoken with the Rape Crisis Counselor in the facility on 04/15/13 and 04/16/13. She stated the counselor had a private interview with Resident #1 on 04/16/13 and would return weekly as needed. She further stated Resident #2 refused the service. Interview with the contracted Psychiatric Services physician, on 04/16/13 at 3:20 PM, revealed he had seen and evaluated Resident #1 and Resident #2 on that day. 3. Interviews with LPN #2 on 04/16/13 at 3:45 PM, RN #1 on 04/17/13 at 9:15 AM, and RN #2 on 04/21/13 at 8:30 PM revealed SRNA #1 left the facility immediately after the incident and had not returned. RN #2 observed SRNA #1 leave via the side exit. LPN #2 went into the parking lot and confirmed SRNA #1's car was gone. Review of the letter addressed to SRNA #1, dated 04/12/13, revealed the following: "Effective immediately, you are no longer an employee of (this facility). You are not to come to this facility for any reason. Your pay check will be mailed to you." The letter was signed by the Administrator. A review of the Certified Letter ticket confirmed the letter was sent as alleged. 4. Review of the Physician's notes revealed he interviewed all one hundred and one (101) residents in the facility between 04/12/13 and 04/15/13. A physical examination was performed on ninety-five (95) residents, six (6) residents refused the examination, but did participate in the interview. Continued review revealed only Resident #1 and Resident #2 had identified concerns. All other residents denied any inappropriate sexual behavior or abuse. All physical exams were normal; specifically, there was no bleeding, bruising, discharge or excoriation. During interview on 04/16/13 at 3:10 PM, the Physician confirmed the resident interviews and examinations were completed. 5. Review of the MDS Section D for Mood (PHQ-9) revealed every resident was assessed on 04/12/13 and again one week later, on 04/19/13. Continued review revealed no immediate or delayed reactions to the incident were identified. The assessments included standardized questions related to mood and open-ended questions to identify any specific problems or anxiety. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the assessments would be performed again at the two (2)week mark, on 04/26/13. 6. Interview with SW #1, on 04/15/13 at 3:40 PM, revealed she was in the process of contacting the families/responsible parties of all resident regarding the incident on 04/12/13. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed only five (5) families had not been contacted by 04/16/13. Certified letters were sent to these families on 04/17/13, confirmed by Review of the POS [REDACTED]. Continued review revealed the addressees were informed of an alleged sexual assault at the facility and measures were being taken to ensure all residents were protected. Contact information for any questions or concerns was included. 7. Interview with LPN #2, on 04/16/13 at 3:47 PM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #4 on 04/18/13 at 10:56 AM, and RN #2 on 04/21/13 at 8:30 AM, revealed a security guard was present on the night shift since the incident. In addition, extra staff was on duty at night for added security. Continued interview revealed the security guard and staff patrolled the building and the grounds throughout the night, ensured doors and windows were secure, and checked with staff for any problems. Interview with the Administrator, on 04/24/13 at 9:40 am revealed the security guard had been hired through a local security service and was on duty 10:00 PM until 6:00 AM. In addition, an extra staff person, e.g. Maintenance, Housekeeping, or SRNA was on duty on the night shift, from 11:00 PM until 7:00 AM. She stated male staff who exhibited a strong presence were chosen for the extra shifts at night. 8. Interviews with LPN #1, on 04/15/13 at 2:15 PM, LPN #2 on 04/16/13 at 3:47 PM, RN #1 on 04/17/13 at 9:15 AM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #6 on 04/23/13 at 1:32 PM, East Wing Unit Coordinator on 04/18/13 at 2:15 PM, and SRNA #5 on 04/23/13 at 3:50 PM, revealed all had attended mandatory inservices since the incident of 04/12/13. The training included appropriate responses to a witnessed or reported abuse. Emphasis was on protecting the resident, removing the perpetrator, and reporting immediately. Interview with the Staff Development Coordinator (SDC), on 04/23/13 at 2:27 PM, revealed she had conducted abuse training for every staff member in every department. In order to reach all staff quickly, training was provided in a variety of ways, including classroom setting, telephone inservice, and person-to-person training on the units and in all departments. Continued interview and review of the inservice agenda revealed topics covered included, but were not limited to the different types of abuse, identifying suspicious behaviors, how to respond if abuse is observed or suspected, protecting the resident, and reporting to the Charge Nurse, the Administrator, the Social Services Director and the DON. Continued interview with SDC and review of sign-in sheets revealed three (3) staff members had not yet received the training: one was on maternity leave, one was on vacation, and one was a PRN (as needed) staff who had not worked since the incident. Staff signatures were confirmed by cross-check with a master list of facility employees. Document review verified the PIN numbers required for clocking in had been changed by the facility for the three (3) staff still requiring the training. A notice was posted at the time clock instructing these staff to report to the SDC, DON, ADON or Administrator prior to reporting to their unit of duty. 9. Review of the sign-in sheets revealed all Nurses who served in a supervisory or administrative role attended abuse training on 04/16/13. The training was conducted by the DON and the ADON. Instructional methods included handouts, discussion and a Question and Answer session. Topics included identifying abusive situations, protecting the resident, investigating the incident and reporting to the family, physician and State Agency. 10. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the Abuse Investigation Team consisted of the Administrator, the DON, the ADON and the Social Services Director (SSD). All allegations of abuse were to be reviewed daily, seven days a week, to determine who would be in charge of the investigation. Review of the Continuous Quality Improvement (CQI) tool for "Abuse Investigation and Reporting" and continued interview with the Administrator revealed the tool would be used for every allegation of abuse. The CQI tool included a checklist to ensure every step in the investigation process, including but not limited to identifying the concern, protecting the resident, suspension of an alleged employee perpetrator, contacting the physician and family, investigating the incident and reporting to the appropriate State Agency. 11. Interview with the Quality Assurance (QA) Nurse, on 04/23/12 revealed the Medical Director was very involved with the QA committee. He attended at least quarterly, but usually every month. Review of QA meeting sign-in sheets confirmed his attendance, either in person or by phone. She stated the Medical Director took an active role by making recommendations and reviewing policy changes. Interview with the Medical Director, on 04/16/13 at 3:08 PM, revealed all allegations of abuse were discussed in monthly QA meetings. He stated there had not been a formal QA meeting related to the incident of 04/12/13 but a meeting was scheduled for the following day. He further stated he had been in close contact with the Administrator thus far in the follow up to the incident, and been active in interviewing and examining every resident. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the facility's QA committee met on 04/17/13 to review the incident of 04/12/13. Review of the sign-in sheet revealed the meeting was attended by the Administrator, the DON, the ADON, the QA Nurse, and the Social Services Department. The sign-in sheet indicated the Medical Director attended via telephone. The Administrator stated the meeting included a detailed review of the AOC as it had been completed on that date. Subsequent revisions were made prior to the AOC being accepted by the State Survey Agency. The Administrator stated the Medical Director was in agreement with the AOC and had no additional recommendations. 12. Intervi

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure all alleged violations of mistreatment, neglect, or abuse were thoroughly investigated and reported to the State Survey Agency and to ensure residents were protected from further abuse for two (2) of five (5) sampled residents (Resident #2 and Resident #1). On 01/25/13, the facility received an allegation of abuse from Resident #2, who reported State Registered Nurse Aide (SRNA) #1 got in his/her bed and straddled him/her. Two (2) Social Workers (SW) interviewed Resident #2 and submitted written statements of their conversations with the resident to Administration. During interview with SW #1, and upon review of the written statements, it was revealed both SW's reported Resident #2 referred to a leaking water heater over his/her head and that Resident #2 had hallucinations. Interviews with Administrative Staff revealed they determined, based on the SW interviews, the resident's confusion and changing of the story, and SRNA #1's adamant denial of the incident, there was not a credible allegation to be thoroughly investigated or reported. SRNA #1 was allowed to continue working directly with residents. On 04/12/13 at approximately 2:45 AM, Registered Nurse (RN) #1 entered the room of Resident #1 and observed Resident #1 to be lying sideways on the bed while SRNA #1 was standing between Resident #1's open legs. During interview, RN #1 revealed SRNA #1 immediately began adjusting his pants and moved away from Resident #1. RN #1 stated she turned on the light and noted SRNA #1 had an erection which was clearly visible through his pants, and his belt was open with the ends of the belt hanging down on both sides. Interview with the investigating detective revealed SRNA #1 was arrested and charged under the Elder Justice Act, which prohibited abuse, and that a criminal investigation was ongoing. (Refer to F223) The facility's failure to ensure all abuse allegations were reported immediately and thoroughly investigated to prevent further abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 04/15/13 and was determined to exist on 01/25/13. The facility was notified of the Immediate Jeopardy on 04/15/13. The facility provided an acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) on 04/23/13, with the facility alleging the IJ had been removed on 04/18/13. On 04/24/13, the State Survey Agency verified the IJ was removed on 04/18/13 as alleged, with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-225, at a Scope and Severity (S/S) of a "D" while the facility developed and implemented its Plan of Correction and the facility's Quality Assurance Program continued to monitor and ensure residents were protected from abuse. The findings include: Review of the facility's policy titled "Policy on Abuse", undated, revealed the facility would actively promote the absence of abuse from all individuals. The facility would investigate all alleged violations; protect residents during the investigation; and, would report abusive situations to the required regulatory agencies. Further review of the policy revealed any employee involved in an allegation of abuse or neglect would be suspended immediately pending investigation, and all allegations and investigation results would be reported to the appropriate State Agency. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed Resident #2 alleged, a few months ago (01/25/13), SRNA #1 had straddled him/her in the bed. However, based on Resident #2's history of confusion; seeing things that weren't there; being treated for [REDACTED]. Therefore, the alleged perpetrator was not suspended and continued to provide direct resident care. Review of the staffing schedule for January 2013 revealed SRNA #1 was working the night shift on 01/25/13 on the East Hall where Resident #2 resided. Continued review revealed SRNA #1 worked the 11-7 shift on the East Hall nearly every night, including 01/01/13 through 01/10/13, and 01/15/13 through 01/31/13. Continued review of the staffing schedule revealed SRNA #1 continued working regularly, up to and including the night shift of 04/12/13. On 04/12/13, the State Survey Agency received a report from the facility of a "possible sexual assault" when an employee was observed in a "compromising position" with Resident #1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed on 04/12/13, at approximately 2:45 AM, the House Supervisor (HS)/RN #1 on the night shift entered Resident #1's room and observed SRNA #1 with his belt unbuckled and an erection visible through his pants. Interview with RN #1, on 04/17/13 at 9:15 AM, revealed the resident's bottom was at the edge of the bed and his/her legs were bent at the hips and the knees, and the resident's knees were apart and up in the air. Per interview, SRNA #1 was standing between Resident #1's legs in a crouching position, with his knees bent slightly and one hand on each of the resident's legs. During an interview with Resident #1, on 04/12/13 at 4:50 PM, the resident stated "I was raped last night". On continued interview, Resident #1 stated there was one other incident "a long time ago" and she named SRNA #1 by name. The resident stated "he hurt me up inside" and SRNA #1 said if the resident told anyone, he would just say the resident was lying. Interview with the Medical Director, on 04/16/13 at 3:10 PM, revealed he recalled Resident #2 had made an allegation of some sort, and he knew the facility did some sort of investigation. However, interview with the Adminitrator revealed no investigaiton had been completed. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the Administrative Team including the Administrator, DON, ADON and Social Worker were involved in the investigations of abuse and had been educated by the contracted Nurse Consultant related to identifying, reporting and investigating allegations of abuse. She further stated she was not involved in the interviews with Resident #2; however both Social Workers reported Resident #2 denied SRNA #1 got into bed with him/her bed and stated "I wish he/she (Resident #2) had said something". The Administrator further stated, because Resident #2 did not continue to claim an allegation against SRNA #1, no further investigation was warranted. She stated the facility stopped, but should have investigated further to ensure other residents were protected. The facility provided an acceptable AOC on 04/23/13 with an alleged removal of the IJ on 04/18/13. Review of the AOC by the State Survey Agency revealed the facility implemented the following actions: 1. The facility immediately initiated an investigation on 04/12/13 at 2:45 AM. The Police Department (PD), the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG, referred to as State Agency), and the Medical Director were notified. 2. Residents #1 and #2 were sent to the hospital for evaluation on 04/12/13. Both residents returned to the facility the same day and were offered follow-up counseling by the consultant Psychiatric Services and/or the Rape Crisis Center. 3. The identified staff member was removed immediately and sent a certified letter terminating his employment on 04/13/13. 4. All residents were interviewed by the Medical Director to determine if they had experienced any potential negative effects related to the allegation. All residents, except six (6) who refused, were physically examined by the Medical Director, beginning 04/12/13 and completed on 04/15/13. 5. The Social Services staff completed the PHQ9 interview, or the PHQ9-OV Assessment for mood/anxiety on 04/12/13. No resident had a score on the PHQ9 interview or the PHQ9-OV Assessment that indicated any mood or anxiety concerns. The facility was to repeat the interviews/assessments in one week and in two weeks, to evaluate for any delayed effects experienced by the residents. 6. The families and/or responsible parties for all residents were contacted and informed of the allegation. The Social Services staff, the Director of Nursing, and the Assistant Director of Nursing phoned each party beginning on 04/12/13. Any family and/or responsible party that could not be reached by phone by 04/16/13 was sent a certified letter on 04/17/13. 7. The facility employed a security officer for the night shift, beginning 04/13/13 and ongoing. In addition, increased staff on the night shift for added security, beginning 04/12/13. 8. All facility staff was inserviced on abuse and the facility's abuse policy, including, but not limited to: Identification, protection of residents, and reporting of abuse, as provided by the Staff Development Coordinator on 04/12/13 through 04/16/13. Any staff on leave, vacation, or unavailable for the inservice was locked out of the time clock, and will not be able to clock in or work until completing the inservice education. 9. All nurse supervisors and administrative nurses received inservice education on the investigation and reporting of abuse as provided by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 04/16/13, including but not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations and findings. 10. All allegations are to be reviewed seven (7) days per week by the facility's investigation team, consisting of the Administrator, the Social Service Director, the DON and the ADON, to determine which team members will investigate and report the allegation to the required authorities. 11. The facility's Quality Assurance Committee, with the Medical Director, met on 04/17/13 to review the circumstances of the allegation and all interventions which had been or would be implemented by the facility. 12. The CQI indicator for the monitoring of compliance with the components of the abuse regulation, including, but not limited to, investigating and reporting of abuse, are to be utilized with each allegation. The CQI indicator is to be used at least weekly for four (4) weeks, then monthly under the supervision of the Administrator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed she had called 911 immediately after receiving the report of the incident, related to Resident #1. She stated the PD responded immediately. Interview with the Lead Detective, on 04/15/13 at 1:40 PM, revealed he had assumed charge of the investigation on the morning of 04/12/13, from the night shift officer who responded to the 911 call. 2. A review of hospital records revealed Resident #1 and Resident #2 were evaluated in the ED and transferred back to the facility on [DATE]. Interview with Resident #2, on 04/23/13 at 2:50 PM revealed a lot of people had been talking to her, but she did not remember who. Interview with Resident #1, on 04/23/13 at 3:00 PM, revealed she had talked to the Rape Crisis Counselor. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed she had spoken with the Rape Crisis Counselor in the facility on 04/15/13 and 04/16/13. She stated the counselor had a private interview with Resident #1 on 04/16/13 and would return weekly as needed. She further stated Resident #2 refused the service. Interview with the contracted Psychiatric Services physician, on 04/16/13 at 3:20 PM, revealed he had seen and evaluated Resident #1 and Resident #2 on that day. 3. Interviews with LPN #2 on 04/16/13 at 3:45 PM, RN #1 on 04/17/13 at 9:15 AM, and RN #2 on 04/21/13 at 8:30 PM revealed SRNA #1 left the facility immediately after the incident and had not returned. RN #2 observed SRNA #1 leave via the side exit. LPN #2 went into the parking lot and confirmed SRNA #1's car was gone. Review of the letter addressed to SRNA #1, dated 04/12/13, revealed the following: "Effective immediately, you are no longer an employee of (this facility). You are not to come to this facility for any reason. Your pay check will be mailed to you." The letter was signed by the Administrator. A review of the Certified Letter ticket confirmed the letter was sent as alleged. 4. Review of the Physician's notes revealed he interviewed all one hundred and one (101) residents in the facility between 04/12/13 and 04/15/13. A physical examination was performed on ninety-five (95) residents, six (6) residents refused the examination, but did participate in the interview. Continued review revealed only Resident #1 and Resident #2 had identified concerns. All other residents denied any inappropriate sexual behavior or abuse. All physical exams were normal; specifically, there was no bleeding, bruising, discharge or excoriation. During interview on 04/16/13 at 3:10 PM, the Physician confirmed the resident interviews and examinations were completed. 5. Review of the MDS Section D for Mood (PHQ-9) revealed every resident was assessed on 04/12/13 and again one week later, on 04/19/13. Continued review revealed no immediate or delayed reactions to the incident were identified. The assessments included standardized questions related to mood and open-ended questions to identify any specific problems or anxiety. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the assessments would be performed again at the two (2)week mark, on 04/26/13. 6. Interview with SW #1, on 04/15/13 at 3:40 PM, revealed she was in the process of contacting the families/responsible parties of all resident regarding the incident on 04/12/13. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed only five (5) families had not been contacted by 04/16/13. Certified letters were sent to these families on 04/17/13, confirmed by Review of the POS [REDACTED]. Continued review revealed the addressees were informed of an alleged sexual assault at the facility and measures were being taken to ensure all residents were protected. Contact information for any questions or concerns was included. 7. Interview with LPN #2 on 04/16/13 at 3:47 PM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #4 on 04/18/13 at 10:56 AM, and RN #2 on 04/21/13 at 8:30 AM, revealed a security guard was present on the night shift since the incident. In addition, extra staff was on duty at night for added security. Continued interview revealed the security guard and staff patrolled the building and the grounds throughout the night, ensured doors and windows were secure, and checked with staff for any problems. Interview with the Administrator, on 04/24/13 at 9:40 am revealed the security guard had been hired through a local security service and was on duty 10:00 PM until 6:00 AM. In addition, an extra staff person, e.g. Maintenance, Housekeeping, or SRNA was on duty on the night shift, from 11:00 PM until 7:00 AM. She stated male staff who exhibited a strong presence were chosen for the extra shifts at night. 8. Interviews with LPN #1 on 04/15/13 at 2:15 PM, LPN #2 on 04/16/13 at 3:47 PM, RN #1 on 04/17/13 at 9:15 AM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #6 on 04/23/13 at 1:32 PM, East Wing Unit Coordinator on 04/18/13 at 2:15 PM, and SRNA #5 on 04/23/13 at 3:50 PM, revealed all had attended mandatory inservices since the incident of 04/12/13. The training included appropriate responses to a witnessed or reported abuse. Emphasis was on protecting the resident, removing the perpetrator, and reporting immediately. Interview with the Staff Development Coordinator (SDC), on 04/23/13 at 2:27 PM, revealed she had conducted abuse training for every staff member in every department. In order to reach all staff quickly, training was provided in a variety of ways, including classroom setting, telephone inservice, and person-to-person training on the units and in all departments. Continued interview and review of the inservice agenda revealed topics covered included, but were not limited to the different types of abuse, identifying suspicious behaviors, how to respond if abuse is observed or suspected, protecting the resident, and reporting to the charge nurse, the Administrator, the Social Services Director and the DON. Continued interview with SDC and review of sign-in sheets revealed three (3) staff members had not yet received the training: one was on maternity leave, one was on vacation, and one was a PRN (as needed) staff who had not worked since the incident. Staff signatures were confirmed by cross-check with a master list of facility employees. Document review verified the PIN numbers required for clocking in had been changed by the facility for the three (3) staff still requiring the training. A notice was posted at the time clock instructing these staff to report to the SDC, DON, ADON or Administrator prior to reporting to their unit of duty. 9. Review of the sign-in sheets revealed all nurses who served in a supervisory or administrative role attended abuse training on 04/16/13. The training was conducted by the DON and the ADON. Instructional methods included handouts, discussion and a Question and Answer session. Topics included identifying abusive situations, protecting the resident, investigating the incident and reporting to the family, physician and State Agency. 10. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the Abuse Investigation Team consisted of the Administrator, the DON, the ADON and the Social Services Director (SSD). All allegations of abuse were to be reviewed daily, seven days a week, to determine who would be in charge of the investigation. Review of the Continuous Quality Improvement (CQI) tool for "Abuse Investigation and Reporting" and continued interview with the Administrator revealed the tool would be used for every allegation of abuse. The CQI tool included a checklist to ensure every step in the investigation process, including but not limited to identifying the concern, protecting the resident, suspension of an alleged employee perpetrator, contacting the physician and family, investigating the incident and reporting to the appropriate State Agency. 11. Interview with the Quality Assurance (QA) nurse, on 04/23/12 revealed the Medical Director was very involved with the QA committee. He attended at least quarterly, but usually every month. Review of QA meeting sign-in sheets confirmed his attendance, either in person or by phone. She stated the Medical Director took an active role by making recommendations and reviewing policy changes. Interview with the Medical Director, on 04/16/13 at 3:08 PM, revealed all allegations of abuse were discussed in monthly QA meetings. He stated there had not been a formal QA meeting related to the incident of 04/12/13 but is had been scheduled for the following day. He further stated he had been in close contact with the Administrator thus far in the follow up to the incident, and been active in interviewing and examining every resident. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the facility's QA committee met on 04/17/13 to review the incident of 04/12/13. Review of the sign-in sheet revealed the meeting was attended by the Administrator, the DON, the ADON, the QA nurse, and the Social Services Department. The sign-in sheet indicated the Medical Director attended via telephone. The Administrator stated the meeting included a detailed review of the AOC as it had been completed on that date. Subsequent revisions were made prior to the AOC being accepted by the State Survey Agency. The Administrator stated the Medical Director was in agreement with the AOC and had no additional recommendations. 12. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the CQI tool for Abuse Investigating and Reporting would be utilized with every allegation. Results would be reviewed weekly for four (4) weeks, and monthly thereafter. All results were to be reported to and reviewed with the contracted Nurse Consultant during her monthly visits. The next QA meeting was scheduled for 04/26/13.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the implementation of policies and procedures to prohibit abuse for two (2) of five (5) sampled residents (Resident #1 and #2). On 01/25/13, the facility received an allegation of abuse from Resident #2, who reported State Registered Nurse Aide (SRNA) #1 got in his/her bed and straddled him/her. Two (2) Social Workers (SW) interviewed Resident #2 and gave written accounts of their conversations with the resident. During interview with SW #1, and upon review of the written statements, it was revealed both SWs reported Resident #2 referred to a leaking water heater over his/her head that needed to be fixed immediately, as evidence Resident #2 had hallucinations. Interviews with Administrative Staff revealed they determined, based on the SW interviews, the resident's confusion and changing of the story, and SRNA #1's adamant denial of the incident, there was not a credible allegation to be thoroughly investigated or reported. SRNA #1 was allowed to continue working in an unrestricted manner. No further documented evidence related to an investigation was provided. On 04/12/13, the House Supervisor (HS)/Registered Nurse (RN) #1 observed Resident #1 to be lying sideways on the bed, and State Registered Nursing Assistant (SRNA) #1 was standing between Resident #1's open legs. During interview, RN #1 revealed SRNA #1 immediately began adjusting his pants and moved away from Resident #1. RN #1 stated she turned on the light and noted SRNA #1 had an erection which was clearly visible through his pants, and his belt was open with the ends of the belt hanging down on either side. Resident #1 reported SRNA #1 was giving therapy "on my bottom". The resident further reported SRNA #1 gave have him/her therapy about once a week. Interview with the investigating detective revealed SRNA #1 was arrested and charged under the Elder Justice Act, which prohibits abuse, and a criminal investigation was ongoing. (Refer to F223 and F225) Based on the findings, the facility's failure to implement its policy related to identifying, investigating, and reporting an allegation of abuse on 01/25/13 has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 04/15/13, and was determined to exist on 01/25/13. The facility was notified of the Immediate Jeopardy on 04/15/13. The facility provided an acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) on 04/23/13, with the facility alleging the IJ had been removed on 04/18/13. On 04/24/13, the State Survey Agency verified the IJ was removed on 04/18/13 as alleged, with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-226 at a Scope and Severity (S/S) of an "D" while the facility develops and implements its Plan of Correction and the facility's Quality Assurance Program continues to monitor and ensure residents are protected from abuse. The findings include: Review of the facility's policy titled "Policy on Abuse", undated, revealed sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Continued review revealed the facility would actively promote the absence of abuse from all individuals. Processes developed to assure the policy was upheld included the following: screening of potential employees; initial and ongoing training of employees; prevention of abuse, neglect, or mistreatment; identification of suspicious events; protection of residents during an investigation; investigation of all alleged violations; and reporting of abusive situations to the required regulatory agencies. Further review revealed policy specifics included but were not limited to the following: any employee involved in an allegation of abuse or neglect would be suspended immediately pending investigation; a thorough examination of the resident would be conducted for any marks, bruises or other injury; the Physician and the resident's legal representative would be notified; and all allegations and investigation results would be reported to the appropriate State Agency, including the State Survey Agency. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed Resident #2 alleged, a few months ago (01/25/13), that SRNA #1 had straddled him/her in the bed. The Administrator further stated two Social Workers (SW) went immediately to interview the resident, who then denied the allegation. The Administrator stated she had discussed the matter with the Social Workers and they determined the initial allegation by Resident #2 was not valid. She further stated the facility declined to conduct a formal investigation, did not suspend the alleged perpetrator, and did not report the allegation to the State Agency. Further interview, on 04/15/13 at 3:05 PM, the Administrator stated she had concluded the initial allegation had no merit, i.e. was not credible, and no further investigation or reporting was warranted. However, review of the facility's policy revealed the facility would investigate all alleged violations, and report abusive situations to the required regulatory agencies. During interview, on 04/12/13 at 5:05 PM, Resident #2 stated SRNA #1 got in his/her bed and straddled him/her, with one leg on each side. The resident reported he/she told SRNA #1, "you better get off me", and he did. Resident #2 stated "it was at least a couple of weeks ago". The resident further stated he/she reported the incident when it occurred, but could not say who he/she reported to, and did not recall anything about an investigation. Review of the staffing schedule for January 2013 revealed SRNA #1 was working the night shift on 01/25/13 on the East Hall where Resident #2 resided. Continued review revealed SRNA #1 worked the 11-7 shift on the East Hall nearly every night, including 01/01/13 through 01/10/13, and 01/15/13 through 01/31/13. Further review revealed SRNA #1 continued working regularly, up to and including the night shift of 04/12/13. However, review of the facility's policy revealed any employee involved in an allegation of abuse or neglect would be suspended immediately pending investigation. On 04/12/13 at 2:45 AM, SRNA #1 was found in a "compromising position" with Resident #1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed the House Supervisor (HS)/RN #1 entered Resident #1's room and observed SRNA #1 with his belt unbuckled and an erection visible through his pants. Resident #1 told RN #1 SRNA #1 was giving him/her therapy "on my bottom". The resident further reported SRNA #1 gave him/her therapy about once a week. During interview, on 04/12/13 at 4:50 PM, Resident #1 stated "I was raped last night" and there was one other incident "a long time ago". Resident #1 referred to SRNA #1 by name and stated SRNA #1 said if the resident told anyone, he would just say the resident was lying. Interview with the Medical Director, on 04/16/13 at 3:10 PM, revealed he recalled Resident #2 had made an allegation of some sort in the past, but he did not recall the details, and he had not interviewed Resident #2 at that time. He stated he was not aware of the regulations related to reporting allegations to the State Agency. He recalled the facility felt Resident #2 was confused when the allegation was made, talked about a radiator, and was being treated for [REDACTED]. The resident stated he/she told the perpetrator, "get off you SOB". The facility provided an acceptable AOC on 04/23/13 with an alleged removal of the IJ on 04/18/13. Review of the AOC by the State Survey Agency revealed the facility implemented the following actions: 1. The facility immediately initiated an investigation on 04/12/13 at 2:45 AM. The Police Department (PD), the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG, referred to as State Agency), and the Medical Director were notified. 2. Residents #1 and #2 were sent to the hospital for evaluation on 04/12/13. Both residents returned to the facility the same day and were offered follow-up counseling by the consultant Psychiatric Services and/or the Rape Crisis Center. 3. The identified staff member was removed immediately and sent a certified letter terminating his employment on 04/13/13. 4. All residents were interviewed by the Medical Director to determine if they had experienced any potential negative effects related to the allegation. All residents, except six (6) who refused, were physically examined by the Medical Director, beginning 04/12/13 and completed on 04/15/13. 5. The Social Services staff completed the PHQ9 interview, or the PHQ9-OV Assessment for mood/anxiety on 04/12/13. No resident had a score on the PHQ9 interview or the PHQ9-OV Assessment that indicated any mood or anxiety concerns. The facility was to repeat the interviews/assessments in one week and in two weeks, to evaluate for any delayed effects experienced by the residents. 6. The families and/or responsible parties for all residents were contacted and informed of the allegation. The Social Services staff, the Director of Nursing, and the Assistant Director of nursing phone each party beginning on 04/12/13. Any family and/or responsible party that could not be reached by phone by 04/16/13 was sent a certified letter on 04/17/13. 7. The facility employed a security officer for the night shift, beginning 04/13/13 and ongoing. In addition, increased staff on the night shift for added security, beginning 04/12/13. 8. All facility staff were inserviced on abuse and the facility abuse policy, including, but not limited to: Identification, protection of residents, and reporting of abuse, as provided by the Staff Development Coordinator on 04/12/13 through 04/16/13. Any staff on leave, vacation, or unavailable for the inservice was locked out of the time clock, and will not be able to clock in or work until completing the inservice education. 9. All nurse supervisors and administrative nurses received inservice education on the investigation and reporting of abuse as provided by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 04/16/13, including but not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations and findings. 10. All allegations are to be reviewed seven days per week by the facility investigation team, consisting of the Administrator, the Social Service Director, the DON and the ADON, to determine which team members will investigate and report the allegation to the required authorities. 11. The facility's Quality Assurance Committee, with the Medical Director, met on 04/17/13 to review the circumstances of the allegation and all interventions which had been or would be implemented by the facility. 12. The CQI indicator for the monitoring of compliance with the components of the abuse regulation, including, but not limited to, investigating and reporting of abuse, are to be utilized with each allegation. The CQI indicator is to be used at least weekly for four (4) weeks, then monthly under the supervision of the Administrator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed she had called 9-1-1 immediately after receiving the report of the incident. She stated the PD responded immediately. Interview with the Lead Detective, on 04/15/13 at 1:40 PM, revealed he had assumed charge of the investigation on the morning of 04/12/13, from the night shift officer who responded to the 9-1-1 call. 2. A review of hospital records revealed Resident #1 and Resident #2 were evaluated in the ED and transferred back to the facility on [DATE]. Interview with Resident #2, on 04/23/13 at 2:50 PM revealed a lot of people had been talking to her, but she did not remember who. Interview with Resident #1, on 04/23/13 at 3:00 PM, revealed she had talked to the Rape Crisis Counselor. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed she had spoken with the Rape Crisis Counselor in the facility on 04/15/13 and 04/16/13. She stated the counselor had a private interview with Resident #1 on 04/16/13 and would return weekly as needed. She further stated Resident #2 refused the service. Interview with the contracted Psychiatric Services physician, on 04/16/13 at 3:20 PM, revealed he had seen and evaluated Resident #1 and Resident #2 on that day. 3. Interviews with LPN #2, on 04/16/13 at 3:45 PM, RN #1 on 04/17/13 at 9:15 AM, and RN #2 on 04/21/13 at 8:30 PM revealed SRNA #1 had left the facility immediately after the incident and had not returned. RN #2 observed SRNA #1 leave via the side exit. LPN #2 went into the parking lot and confirmed SRNA #1's car was gone. Review of the letter addressed to SRNA #1, dated 04/12/13, revealed the following: "Effective immediately, you are no longer an employee of (this facility). You are not to come to this facility for any reason. Your pay check will be mailed to you." The letter was signed by the Administrator. A review of the Certified Letter ticket confirmed the letter was sent as alleged. 4. Review of the Physician's notes revealed he interviewed all 101 residents in the facility between 04/12/13 and 04/15/13. A physical exam was performed on 98 residents, 6 residents refused the exam, but did participate in the interview. Continued review revealed only Resident #1 and Resident #2 had identified concerns. All other residents denied any inappropriate sexual behavior or abuse. All physical exams were normal. Specifically, the there was no bleeding, bruising, discharge or excoriation. 5. Review of the MDS Section D for Mood (PHQ-9) revealed every resident was assessed on 04/12/13 and again one week later, on 04/19/13. Continued review revealed no immediate or delayed reactions to the incident were identified. The assessments included standardized questions related to mood and open-ended questions to identify any specific problems or anxiety. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the assessments would be performed again at the two week mark, on 04/26/13. 6. Interview with SW #1, on 04/15/13 at 3:40 PM, revealed she was in the process of contacting the families / responsible parties of all resident regarding the incident on 04/12/13. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed only five (5) families had not been contacted by 04/16/13. Certified Letters were sent to these families on 04/17/13, confirmed by Review of the POS [REDACTED]. Continued review revealed the addressees were informed of an alleged sexual assault at the facility and measures were being taken to ensure all residents were protected. Contact information for any questions or concerns was included. 7. Interview with LPN #2, on 04/16/13 at 3:47 PM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #4 on 04/18/13 at 10:56 AM, and RN #2 on 04/21/13 at 8:30 AM, revealed a security guard was present on the night shift since the incident. In addition, extra staff were on duty at night for added security. Continued interview revealed the security guard and staff patrolled the building and the grounds throughout the night, ensured doors and windows were secure, and checked with staff for any problems. Interview with the Administrator, on 04/24/13 at 9:40 am revealed the security guard had been hired through a local security service and was on duty 10:00 PM until 6:00 AM. In addition, an extra staff person, e.g. Maintenance, Housekeeping, or SRNA was on duty on the night shift, from 11:00 PM until 7:00 AM. She stated male staff who exhibited a strong presence were chosen for the extra shifts at night. 8. Interviews with LPN #1, on 04/15/13 at 2:15 PM, LPN #2 on 04/16/13 at 3:47 PM, RN #1 on 04/17/13 at 9:15 AM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #6 on 04/23/13 at 1:32 PM, East Wing Unit Coordinator on 04/18/13 at 2:15 PM, and SRNA #5 on 04/23/13 at 3:50 PM, revealed all had attended mandatory inservices since the incident of 04/12/13. The training included appropriate responses to a witnessed or reported abuse. Emphasis was on protecting the resident, removing the perpetrator, and reporting immediately. Interview with the Staff Development Coordinator (SDC), on 04/23/13 at 2:27 PM, revealed she had conducted abuse training for every staff member in every department. In order to reach all staff quickly, training was provided in a variety of ways, including classroom setting, telephone inservice, and person-to-person training on the units and in all departments. Continued interview and review of the inservice agenda revealed topics covered included, but were not limited to the different types of abuse, identifying suspicious behaviors, how to respond if abuse is observed or suspected, protecting the resident, and reporting to the charge nurse, the Administrator, the Social Services Director and the DON. Continued interview with SDC and review of sign-in sheets revealed three (3) staff members had not yet received the training: one was on maternity leave, one was on vacation, and one was a PRN (as needed) staff who had not worked since the incident. Staff signatures were confirmed by cross-check with a master list of facility employees. Document review verified the PIN numbers required for clocking in had been changed by the facility for the three (3) staff still requiring the training. A notice was posted at the time clock instructing these staff to report to the SDC, DON, ADON or Administrator prior to reporting to their unit of duty. 9. Review of the sign-in sheets revealed all nurses who served in a supervisory or administrative role attended abuse training on 04/16/13. The training was conducted by the DON and the ADON. Instructional methods included handouts, discussion and a Question and Answer session. Topics included identifying abusive situations, protecting the resident, investigating the incident and reporting to the family, physician and State Agency. 10. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the Abuse Investigation Team consisted of the Administrator, the DON, the ADON and the Social Services Director (SSD). All allegations of abuse were to be reviewed daily, seven days a week, to determine who would be in charge of the investigation. Review of the Continuous Quality Improvement (CQI) tool for "Abuse Investigation and Reporting" and continued interview with the Administrator revealed the tool would be used for every allegation of abuse. The CQI tool included a checklist to ensure every step in the investigation process, including but not limited to identifying the concern, protecting the resident, suspension of an alleged employee perpetrator, contacting the physician and family, investigating the incident and reporting to the appropriate State Agency. 11. Interview with the Quality Assurance (QA) nurse, on 04/23/12 revealed the Medical Director was very involved with the QA committee. He attended at least quarterly, but usually every month. Review of QA meeting sign-in sheets confirmed his attendance, either in person or by phone. She stated the Medical Director took an active role by making recommendations and reviewing policy changes. Interview with the Medical Director, on 04/16/13 at 3:08 PM, revealed all allegations of abuse were discussed in monthly QA meetings. He stated there had not been a formal QA meeting related to the incident of 04/12/13 but one had been scheduled for the following day. He further stated he had been in close contact with the Administrator thus far in the follow up to the incident, and been active in interviewing and examining every resident. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the facility's QA committee met on 04/17/13 to review the incident of 04/12/13. Review of the sign-in sheet revealed the meeting was attended by the Administrator, the DON, the ADON, the QA nurse, and the Social Services Department. The sign-in sheet indicated the Medical Director attended via telephone. The Administrator stated the meeting included a detailed review of the AOC as it had been completed on that date. Subsequent revisions were made prior to the AOC being accepted by the State Survey Agency. The Administrator stated the Medical Director was in agreement with the AOC and had no additional recommendations. 12. Continued interview with the Administrator, on 04/24/13 at 9:10 AM, revealed the CQI tool for Abuse Investigating and Reporting would be utilized with every allegation. Results would be reviewed weekly for four (4) weeks, and monthly thereafter. All results were to be reported to and reviewed with the contracted Nurse Consultant during her monthly visits. The next QA meeting was scheduled for 04/26/13.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of five (5) sampled residents (Resident #1 and Resident #2). The facility failed to ensure policy and procedures were implemented to protect residents from abuse. On 01/25/13, Resident #2 reported an allegation that State Registered Nurse Aide (SRNA) #1 got in his/her bed and straddled him/her. Two (2) Social Workers (SW) interviewed Resident #2 and documented written statements of their conversations with Resident #2. During interview with SW #1, and review of the written statements, it was revealed both SWs reported Resident #2 referred to a leaking water heater over his/her head that needed to be fixed immediately and that Resident #2 had hallucinations. Interviews with Administrative Staff revealed they determined, based on the SW interviews, that the resident's confusion and changing of his/her story, and SRNA #1's adamant denial of the incident, there was not a credible allegation to be thoroughly investigated or reported. SRNA #1 was allowed to continue working directly with residents. There was no documented evidence the facility's Administration ensured a thorough investigation was completed to ensure the protection of other residents from potential abuse. On 04/12/13, at approximately 2:45 AM, Registered Nurse (RN) #1 entered the room of Resident #1. She observed Resident #1 to be lying sideways on the bed and State Registered Nursing Assistant (SRNA) #1 was standing between Resident #1's open legs. During interview, RN #1 revealed SRNA #1 immediately began adjusting his pants and moved away from Resident #1. RN #1 stated she turned on the light and noted SRNA #1 had an erection which was clearly visible through his pants and his belt was open with the ends of the belt hanging down on either side. Interview with the investigating detective revealed SRNA #1 was arrested and charged under the Elder Justice Act, which prohibited abuse and a criminal investigation was ongoing. The facility Administration's failure to implement its policy related to identifying, investigating, protecting residents from further abuse and reporting an allegation of abuse against SRNA #1 on 01/25/13 has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 04/15/13 and was determined to exist on 01/25/13. The facility was notified of the Immediate Jeopardy on 04/15/13. (Refer to F-223, F-225 and F226) The facility provided an acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) on 04/23/13, with the facility alleging the IJ had been removed on 04/18/13. On 04/24/13, the State Survey Agency verified the IJ was removed on 04/18/13 as alleged with remaining non-compliance 42 CFR 483.75 Administration, F-490 at a Scope and Severity (S/S) of a "D" while the facility developed and implemented its Plan of Correction and the facility's Quality Assurance Program continued to monitor and ensure residents were protected from abuse. The findings include: The facility failed to ensure all alleged violations of mistreatment, neglect, or abuse were thoroughly investigated and reported to the State Agency per facility policy and per regulations. In addition the facility's Administration failed to ensure residents were protected from further abuse. Review of the facility's policy titled "Policy on Abuse", undated, revealed the facility would actively promote the absence of abuse from all individuals; protect residents during an investigation; investigate all alleged violations; and report abusive situations to the required regulatory agencies. Further review revealed any employee involved in an allegation of abuse or neglect would be suspended immediately pending investigation, and all allegations and investigation results would be reported to the appropriate State Agency, including the State Survey Agency. Interview and record review revealed the facility failed to thoroughly investigate an allegation made by Resident #2, on 01/25/13, that State Registered Nursing Assistant (SRNA) #1 had straddled him/her in the bed. In addition, the Administration failed to report the allegation of abuse to the State Agency. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed Resident #2 alleged, a few months ago (01/25/13), SRNA #1 had straddled him/her in the bed. She stated two Social Workers (SW) went immediately to interview the resident, who then denied the allegation. Continued interview with the Administrator, on 04/15/13 at 3:05 PM, revealed based on the resident's confusion at the time of the allegation, and the resident changing his/her story, the Administrator concluded the initial allegation had no merit and was not credible, and therefore no further investigation or reporting was warranted. However, interview with the Medical Director, on 04/16/13 at 3:10 PM, revealed while interviewing Resident #2 on 04/12/13, the resident reported again that someone, an employee, straddled him/her some time ago and he/she told the perpetrator, "get off you SOB". Further interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the facility should have investigated the allegation to ensure other residents were protected. Review of the State Agency Intake Information, dated 04/12/13 (approximately three months after the allegation made by Resident #2 against SRNA #1), revealed the facility reported an incident of "possible sexual assault" when SRNA #1 was observed in a "compromising position" with Resident #1. During interview, on 04/12/13 at 4:50 PM, Resident #1 stated "I was raped last night" and referred to SRNA #1 by name. The facility provided an acceptable AOC on 04/23/13 with an alleged removal of the IJ on 04/18/13. Review of the AOC by the State Survey Agency revealed the facility implemented the following actions: 1. The facility immediately initiated an investigation on 04/12/13 at 2:45 AM. The Police Department (PD), the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG, referred to as State Agency), and the Medical Director were notified. 2. Residents #1 and #2 were sent to the hospital for evaluation on 04/12/13. Both residents returned to the facility the same day and were offered follow-up counseling by the consultant Psychiatric Services and/or the Rape Crisis Center. 3. The contracted Nurse Consultant was contacted on 04/12/13 for notification and review of the allegation, and discussion and planning of all interventions initiated by the Administrator. 4. The identified staff member was removed immediately and sent a certified letter terminating his employment on 04/13/13. 5. All residents were interviewed by the Medical Director to determine if they had experienced any potential negative effects related to the allegation. All residents, except six (6) who refused, were physically examined by the Medical Director, beginning 04/12/13 and completed on 04/15/13. 6. The Social Services staff completed the PHQ9 interview, or the PHQ9-OV Assessment for mood/anxiety on 04/12/13. No resident had a score on the PHQ9 interview or the PHQ9-OV Assessment that indicated any mood or anxiety concerns. The facility was to repeat the interviews/assessments in one week and in two weeks, to evaluate for any delayed effects experienced by the residents. 7. The Administrator, Social Services Director, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were educated on the investigation and reporting of abuse as provided by the contracted Nurse Consultant on 04/16/13. Training topics included, but were not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations and findings. 8. All nurse supervisors and administrative nurses received inservice education on the investigation and reporting of abuse as provided by the DON and the ADON on 04/16/13, including but not limited to: identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting of allegations and findings. 9. The facility's Quality Assurance (QA) Committee, with the Medical Director, met on 04/17/13 to review the circumstances of the allegation and all interventions which had been or would be implemented by the facility. 10. All allegations are to be reviewed seven days per week by the facility investigation team, consisting of the Administrator, the Social Service Director, the DON and the ADON, to determine which team members will investigate and report the allegation to the required authorities. 11. The Administrator will report all findings and actions of the facility's investigation team to the contracted Nurse Consultant with each allegation to confirm that all necessary investigation and reporting interventions have been initiated. Further education and consultation will be provided immediately by the Nurse Consultant if any concerns are identified. 12. The CQI indicator for the monitoring of compliance with the components of the abuse regulation, including, but not limited to, investigating and reporting of abuse, are to be utilized with each allegation. The CQI indicator is to be used at least weekly for four (4) weeks, then monthly under the supervision of the Administrator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator, on 04/12/13 at 2:10 PM, revealed she had called 9-1-1 immediately after receiving the report of the incident. She stated the PD responded immediately. Interview with the Lead Detective, on 04/15/13 at 1:40 PM, revealed he had assumed charge of the investigation on the morning of 04/12/13, from the night shift officer who responded to the 9-1-1 call. 2. A review of hospital records revealed Resident #1 and Resident #2 were evaluated in the ED and transferred back to the facility on [DATE]. Interview with Resident #2, on 04/23/13 at 2:50 PM revealed a lot of people had been talking to her, but she did not remember who. Interview with Resident #1, on 04/23/13 at 3:00 PM, revealed she had talked to the Rape Crisis Counselor, but she did not think she needed to. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed she had spoken with the Rape Crisis Counselor in the facility on 04/15/13 and 04/16/13. She stated the counselor had a private interview with Resident #1 on 04/16/13 and would return weekly as needed. She further stated Resident #2 refused the service. Interview with the contracted Psychiatric Services physician, on 04/16/13 at 3:20 PM, and review of examination notes, revealed he had seen and evaluated Resident #1 and Resident #2 on that day. 3. The contracted Nurse Consultant was present in the facility on 04/12/13 when the State Survey Agency began their investigation. She was actively involved in assisting with the survey process and was observed in consultation with the Administrator. During interview, on 04/12/13 at 4:00 PM, the Nurse Consultant revealed the decision had been made for the Medical Director to interview/examine every resident in the facility, not just the female residents on the hall where Resident #2 resided. 4. Interviews with LPN #2, on 04/16/13 at 3:45 PM, RN #1 on 04/17/13 at 9:15 AM, and RN #2 on 04/21/13 at 8:30 PM revealed SRNA #1 had left the facility immediately after the incident and had not returned. RN #2 observed SRNA #1 leave via the side exit. LPN #2 went into the parking lot and confirmed SRNA #1's car was gone. Review of the letter addressed to SRNA #1, dated 04/12/13, revealed the following: "Effective immediately, you are no longer an employee of (this facility). You are not to come to this facility for any reason. Your pay check will be mailed to you." The letter was signed by the Administrator. A review of the Certified Letter ticket confirmed the letter was sent as alleged. 5. Review of the Medical Director's notes revealed he interviewed all 101 residents in the facility between 04/12/13 and 04/15/13. A physical exam was performed on 98 residents, 6 residents refused the exam, but did participate in the interview. Continued review revealed only Resident #1 and Resident #2 had identified concerns. All other residents denied any inappropriate sexual behavior or abuse. All physical exams were normal. Specifically, the absence of bleeding, bruising, discharge or excoriation was documented by the Medical Director. 6. Review of the MDS Section D for Mood (PHQ-9) revealed every resident was assessed on 04/12/13 and again one week later, on 04/19/13. Continued review revealed no immediate or delayed reactions to the incident were identified. The assessments included standardized questions related to mood and open-ended questions to identify any specific problems or anxiety. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the assessments would be performed again at the two week mark, on 04/26/13. 7. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the contracted Nurse Consultant provided inservice education to the Administrator, the Social Services Director and staff, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on 04/16/13. Review of the sign-in sheets revealed all parties attended the inservice. Topics included identification of events requiring investigation; interviewing of residents, staff and all witnesses; and reporting allegations and findings. Methods of instruction included discussion, handouts and a PowerPoint presentation. 8. Interviews with LPN #1, on 04/15/13 at 2:15 PM, LPN #2 on 04/16/13 at 3:47 PM, RN #1 on 04/17/13 at 9:15 AM, SRNA #2 on 04/18/13 at 10:24 AM, SRNA #6 on 04/23/13 at 1:32 PM, East Wing Unit Coordinator on 04/18/13 at 2:15 PM, and SRNA #5 on 04/23/13 at 3:50 PM, revealed all had attended mandatory inservices since the incident of 04/12/13. The training included appropriate responses to a witnessed or reported abuse. Emphasis was on protecting the resident, removing the perpetrator, and reporting immediately. 9. Interview with the Quality Assurance (QA) nurse, on 04/23/12 revealed the Medical Director was very involved with the QA committee. He attended at least quarterly, but usually every month. Review of QA meeting sign-in sheets confirmed his attendance, either in person or by phone. She stated the Medical Director took an active role by making recommendations and reviewing policy changes. Interview with the Medical Director, on 04/16/13 at 3:08 PM, revealed all allegations of abuse were discussed in monthly QA meetings. He stated there had not been a formal QA meeting related to the incident of 04/12/13 but one had been scheduled for the following day. He further stated he had been in close contact with the Administrator thus far in the follow up to the incident, and been active in interviewing and examining every resident. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the facility's QA committee met on 04/17/13 to review the incident of 04/12/13. Review of the sign-in sheet revealed the meeting was attended by the Administrator, the DON, the ADON, the QA nurse, and the Social Services Department. The sign-in sheet indicated the Medical Director attended via telephone. The Administrator stated the meeting included a detailed review of the AOC as it had been completed on that date. Subsequent revisions were made prior to the AOC being accepted by the State Survey Agency. The Administrator stated the Medical Director was in agreement with the AOC and had no additional recommendations. 10. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the Abuse Investigation Team consisted of the Administrator, the DON, the ADON and the Social Services Director (SSD). All allegations of abuse were to be reviewed daily, seven days a week, to determine who would be in charge of the investigation. Review of the Continuous Quality Improvement (CQI) tool for "Abuse Investigation and Reporting" and continued interview with the Administrator revealed the tool would be used for every allegation of abuse. The CQI tool included a checklist to ensure every step in the investigation process, including but not limited to identifying the concern, protecting the resident, suspension of an alleged employee perpetrator, contacting the physician and family, investigating the incident and reporting to the appropriate State Agency. 11. Interview with the Administrator, on 04/24/13 at 9:40 AM, revealed the contracted Nurse Consultant visited monthly and would in the future be reviewing all CQI data to verify all investigation interventions and reporting requirements had been initiated. She stated the Nurse Consultant would prepare a report based on the CQI data and report to the facility Board (owners) monthly as well. 12. Continued interview with the Administrator, on 04/24/13 at 9:10 AM, revealed the CQI tool for Abuse Investigating and Reporting would be utilized with every allegation. Results would be reviewed weekly for four (4) weeks, and monthly thereafter. All results were to be reported to and reviewed with the contracted Nurse Consultant during her monthly visits. The next QA meeting was scheduled for 04/26/13.