Every finding on record at Carmel Home

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Pharmacist reviewed residents' drug regimens at least once a month for 4 of 5 residents sampled for Medication Regimen Review (MRR). Resident (R)4, R5, R10, and R18). The findings include:Review of the facility policy titled, Medication Regimen Review, undated, revealed, the facility ensured that all residents' medication regimens were regularly reviewed to optimize therapeutic outcomes, prevent adverse reactions, and comply with regulatory requirements. Per policy review, a pharmacist was to conduct periodic reviews of each resident's medication regimen to assess effectiveness, identify potential risks, and recommend necessary adjustments to enhance resident safety and care. Policy review revealed under, Guidelines a licensed pharmacist was to review each resident's medication regimen at least once a month. Continued policy review revealed the medication regimen review would be conducted following admission, upon any significant change in a resident's health status, and when new medications were added to the resident's regimen. Further review revealed the pharmacist was to document (his/her) findings and recommendations in the resident's medical record, addressing any concerns about the appropriateness, safety, or effectiveness of the medication regimen. In addition, the pharmacist was to provide a written report of the review to the attending physician within 24 hours of the review. Review further revealed all medication regimen reviews, recommendations, and provider responses were to be documented in the resident's medical record in accordance with facility policy and regulatory requirements.Review of the facility's, Pharmacy Service Agreement, signed by the Administrator and the Pharmacist, revealed the scope of services included a licensed pharmacist to be available to conduct routine medication regimen reviews and provide clinical consultation to the staff as requested. Further review of the Agreement revealed the pharmacy was to maintain accurate records of all medications dispensed and provide required reports to the facility in compliance with state and federal regulations.1). Review of the facility's Electronic Medical Record (EMR) revealed the admission Record noted the facility admitted R4 to the facility on [DATE], with diagnoses of major depressive disorder, Alzheimer's Disease, and type 2 diabetes mellitus. Review of the Quarterly Minimum Data Set (MDS) Assessment for R4, with an Assessment Reference Date (ARD) of 01/29/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severely impaired cognition. Continued review of R4's EMR and the paper Medical Chart revealed no documented evidence a licensed Pharmacist had completed the MRR's monthly as required for the months of 12/2025, 01/2026, 02/2026, and 04/2026.2) Review of the facility's EMR for R5, revealed the admission Record noted the facility admitted R5 to the facility on [DATE], with diagnoses of anxiety disorder, Alzheimer's Disease, and chronic kidney disease.Review of R5's Annual MDS Assessment, with an ARD of 01/29/2026, revealed the facility assessed the resident to have a BIMS score of three out of 15, which indicated severely impaired cognition. Continued review of R5's EMR and paper Medical Chart revealed no documented evidence a licensed pharmacist had completed the MRR's monthly as required for the months of 12/2025, 01/2026, 03/2026, and 04/2026.3) Review of the facility's EMR for R10 revealed the admission Record noted the facility admitted the resident on 02/08/2022, with diagnoses of generalized anxiety disorder, Alzheimer's Disease, and other depressive disorders.Review of R10's Quarterly MDS Assessment, with an ARD of 02/26/2026, revealed the facility assessed the resident as having a BIMS score of six out of 15, which indicated severely impaired cognition. Continued review of R10's EMR and paper Medical Chart revealed no documented evidence a licensed Pharmacist had completed the MRR's monthly as required for the months of 12/2025, 01/2026, 02/2026, and 04/2026.4) Review of the facility's EMR for R18 revealed the admission Record noted the facility admitted R18 on 01/04/2024, with diagnoses of anxiety disorder, Alzheimer's Disease, and other seizures.Review of R18's Quarterly Annual MDS Assessment, with an ARD of 02/19/2026, revealed the facility assessed the resident to have a BIMS score of six out of 15, which indicated severely impaired cognition. Continued review of R18's EMR and paper Medical Chart revealed no documented evidence a licensed Pharmacist had completed the MRR's monthly as required for the months of 12/2025, 01/2026, 02/2026, and 04/2026.During an interview on 05/07/2026 at 10:18 AM, the Licensed Pharmacist stated he had signed a general contract with the facility and assumed services for the facility in December 2025. He said he was aware of the consulting part of the contract; however, thought they were still negotiating how all of that would work. The Licensed Pharmacist reported he reviewed patient charts in December, and communicated by telephone with the Director of Nursing (DON) about the reviews; however, had not communicated with the physician or provider. He explained also did a few patient reviews in February and March. The Licensed Pharmacist said he had not provided the facility with documentation of his chart reviews. He stated he had not been aware written reports were required. During the interview when the State Survey Agency (SSA) Surveyor questioned the Pharmacist about recommending gradual dose reductions for psychotropic medications or evaluating the use of an as-needed (PRN) antianxiety medication for residents, the Pharmacist was unable to answer the questions.During an interview on 05/07/2026 at 2:25 PM, the Physician stated the Medical Director had been experiencing health issues for the last three months, so he had been covering for the Medical Director. He said he was just covering for the Medical Director. The Physician reported being aware a pharmacist was to review residents' medications, but that he did not know how often (that was to occur). He explained he did recall signing a few of them. The Physician further stated it was important for medications to be reviewed to monitor for possible adverse reactions (for residents).During an interview on 05/07/2026 at 2:57 PM, the Director of Nursing (DON) stated the facility started using a new pharmacy in December, and that pharmacist had already handled the facility's assisted living residents. She said she had not been aware the MRR's were not being completed by the pharmacist, but thought he had been doing the reviews. The DON explained the pharmacist had done a few but had not consistently done them on a monthly basis. She said the Pharmacist usually called her or left a note in her mailbox (after the reviews). The DON further stated she had not seen any written reports, and additionally said she communicated with the provider about any recommendations the pharmacist had.During an interview on 05/07/2026 at 4:56 PM, the Administrator stated the facility was currently transitioning to a different pharmacy and the MRR's had fell through the cracks. She stated the pharmacist completed some of the MRR reviews in March, but the physician monitored residents' medications monthly during his rounds. The Administrator further stated she expected the MRR's to be completed monthly (as required).

Based on interview, review of the facility's documentation, and review of the Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) Report, the facility failed to electronically submit to CMS complete and accurate direct care staffing information based on its payroll and other verifiable and auditable data in a uniform format according to specifications as established by CMS. The findings include:Review of the facility's Payroll-Based Journal (PBJ) Staffing Report for Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) revealed the facility failed to submit data for that quarter and indicated no data was submitted for the quarter. In an interview with the Business Office Manager (BOM) on 05/06/2026 at 11:34 AM, she stated she was not able to submit the required information. In a continued interview on 05/06/2026 at 11:34 AM, the BOM said her computer had been hacked and needed to be replaced. She reported that, therefore, she had been unable to submit the payroll-based journal (PBJ) information due to those computer issues. The BOM said she received verification codes for her account and tried to log into the system on the Director of Nursing's (DON's) computer; however, it would not let her log in. The BOM provided the State Survey Agency (SSA) Surveyor with the quarter 2 documents, which revealed correct information had been submitted. She also provided approximately 500 pages of computer code which could not be read. In interview with the Director of Nursing (DON) on 05/07/2026 at 2:57 PM, she stated she knew nothing about the facility's Payroll Based Journal (PBJ) report. She further stated that the Administrator and the facility's business office handled all of that.In interview with the Administrator on 05/07/2026 at 4:26 PM, she stated the facility had computer issues, like someone was trying to hack their system. She reported the BOM's computer had to be shut down due to that. The Administrator further stated the BOM had been unable to access her account from the DON's computer and therefore, had been unable to submit the PBJ information.

Based on interview, record review, and review of the facility policy, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, for 4 of 5 sampled for drug regimen review out of the total of 8 sampled residents, (Resident (R)5, R8, R10 and R18).The findings include:Review of the facility policy titled, Unnecessary Medications, undated, revealed the facility was to ensure each resident was free from unnecessary medications. Per policy review, all medications, including psychotropic medications, must be clinically indicated; appropriately dosed; monitored for effectiveness and adverse consequences; and used in accordance with current standards of practice. Continued review revealed an unnecessary medication was any medication used without adequate indication for use; used in excessive dose; used for excessive duration; used without adequate monitoring; used in the presence of adverse consequences indicating the dose should be reduced or discontinued; or any combination of the above.1). Review of the Electronic Health Record (EHR) and Medical Record (paper chart) for R5, of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/29/2026, revealed the facility assessed R5 as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Review of the physician's order for R5 dated 03/18/2025, revealed an order for REXULTI oral tablet two milligrams (mg), give one tablet by mouth at bedtime for dementia with behaviors. Additional review of the orders revealed an order dated 01/27/2026, for Citalopram Hydrobromide (generic for Celexa, an antidepressant) oral tablet 20 mg, give one tablet by mouth one time a day for depression. Continued review of the EHR for R5 of the diagnosis list revealed no diagnosis to indicate the use of an antidepressant or antipsychotic medication. The indication for use of REXULTI (an antipsychotic) was for dementia with behaviors; however, that was not listed as a diagnosis for R5. Review of the facility's Behavior Observation and Side Effect Monitoring for R5 for 04/2026 revealed the resident had wandered 13 out of 30 days. Continued review revealed no documentation that R5 resisted care, exhibited socially inappropriate or disruptive behavior, had physically abusive behavior symptoms, or verbally abusive behavior symptoms.Continued review of the EHR and the Medical Record for R5 revealed no consistent documentation a licensed pharmacist had completed a monthly medication regimen review (MRR) as required. Review revealed since 11/2025, the pharmacist had only completed one MRR review on 02/16/2026. 2). Review of the admission Record revealed the facility admitted R8 to the facility on [DATE], with diagnoses of unspecified dementia with other behavioral disturbance and depression. Continued review of the EHR for R8 revealed the resident had been originally admitted to the facility's Personal Care unit on 11/29/2017.Review of R8's admission MDS Assessment, with an ARD of 04/28/2026, revealed the facility assessed the resident to have a BIMS score of five out of 15, indicating severe cognitive impairment.Review of R8's physician's orders revealed an order dated 03/22/2024, for Clomipramine (a tricyclic antidepressant used to treat obsessive compulsive disorder) 50 mg oral tablet, give one tablet by mouth once daily for depression. Continued review of R8's physician's orders revealed an order dated 01/24/2025, for Sertraline 100mg oral tablet, give one tablet by mouth once daily for depression, and an order dated 08/28/2025, for Seroquel 12.5 mg oral tablet, give one tablet by mouth twice daily for dementia with agitation. However, review further revealed no indication for the use of Seroquel.Review of the facility's, Behavior Observation and Side Effect Monitoring for R8 for 04/2026, revealed documentation noting R8 had one episode of socially inappropriate/disruptive behavioral symptoms. Further review of the EHR and Medical Record (paper chart) for R8 revealed no consistent documentation a licensed pharmacist had completed a monthly MRR as required. Review further revealed since 11/2025, the pharmacist had completed only one MRR review on 02/16/2026. 3). Review of the admission Record revealed the facility admitted R10 to the facility on [DATE], with diagnoses of Alzheimer's Disease, other depressive disorders, and generalized anxiety disorder.Review of R10's Quarterly MDS Assessment with an ARD of 02/26/2026, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment.Review of a physician's order for R10 dated 08/28/2025, revealed an order for Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder) 150 mg oral tablet give one tablet once daily for dementia with agitation. However, there was no documented evidence of R10 having a diagnosis of dementia with agitation.Review of the facility's, Behavior Observation and Side Effect Monitoring for R10 for 04/2026, revealed documentation noting R10 had 10 episodes of socially inappropriate/disruptive behavioral symptoms and three episodes of verbal abuse behavioral symptoms. Continued review of the EHR and Medical Record (paper chart) for R10 revealed no consistent documentation a licensed pharmacist had completed a monthly MRR as required. Additional review revealed since 11/2025, the pharmacist completed only one MRR review on 03/27/2026.4). Review of the admission Record revealed the facility admitted R18 to the facility on [DATE], with diagnoses of Alzheimer's Disease, anxiety disorder, and seizures.Review of R18's Quarterly Annual MDS Assessment, with an ARD of 02/19/2026, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment. Review of the physician's orders for R18 revealed an order for Fluoxetine (generic for Prozac) dated 01/04/2024, 20 mg oral tablet, give one tablet once daily for depression; Mirtazapine (generic for Remeron) 15 mg oral tablet, give one tablet at bedtime for depression; and Seroquel, 12.5 mg oral tablet, give once daily for dementia with agitation. However, further review revealed there was no diagnosis of depression or dementia with agitation noted for R18.Review of the facility's, Behavior Observation and Side Effect Monitoring for R18 for 04/2026, revealed no documented behaviors recorded for 04/2026.Continued review of R18's EHR and Medical Chart (paper chart) revealed no documented evidence a licensed pharmacist had completed the MRR monthly as required for the months of 12/2025, 01/2026, 02/2026, and 04/2026.During interview with the Licensed Pharmacist on 05/07/2026 at 10:18 AM, he stated he signed a general contract with the facility, and assumed services in December 2025. He said he was aware of the consulting part of that contract. The Licensed Pharmacist reported he thought they were still negotiating how all of that would work. He explained in December, he reviewed patient charts and communicated by telephone with the facility's Director of Nursing (DON); however, not with the physician or other provider. The Licensed Pharmacist said he had not provided the facility with documentation of the chart reviews he performed in December. He stated he had done a few patient reviews in February and March. The Licensed Pharmacist reported he was not aware a written report of his reviews was required. During the interview when questioned about recommending gradual dose reductions for psychotropic medications, appropriate diagnoses for the use of antipsychotics in residents with dementia, or evaluating the use of an as-needed (PRN) antianxiety medication, the Licensed Pharmacist could not answer those questions.During interview with the Physician on 05/07/2026 at 2:25 PM, he stated he had been covering for the Medical Director for the last three months due to the Medical Director's health issues. He said he had been providing care to residents on and off for 20 years. The Physician explained the physician(s) did a monthly medication review on each resident and he had prescribed antipsychotic medications for residents with dementia with agitation. He further stated it was important that medications be reviewed to monitor for possible adverse reactions.During interview with the DON on 05/07/2026 at 2:57 PM, she stated the facility started with a new pharmacy in December. She reported she was not aware the pharmacist was not completing the MRR's, as she thought he had been doing those. The DON said, according to the physician, prescribing antipsychotics for residents with a diagnosis of dementia with agitation was okay. She further stated a resident should have a diagnosis indicating the appropriate use of any medication.During interview with the Administrator on 05/07/2026 at 4:56 PM, she stated the physician did a medication review monthly for residents. She said the facility did not usually do dose reductions. The Administrator stated, If we did drug reductions, we would need to send them to a Surveyor's house for a few days. She further stated the pharmacist was aware the MRRs needed to be completed. The Administrator additionally said, they were working on it.

Based on observation, interview, and review of facility policy, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, open tote containing 36 medication cards with pills, unsecured, on the floor outside the medication storage area, which had the potential to affect all 17 residents.The findings include:Review of the facility's policy titled, Storage of Medications, undated, revealed, the facility shall ensure that all medications are stored securely and in accordance with applicable laws, regulations, and best practices to maintain their integrity and ensure the safety of residents. Review of the policy further revealed all medications were to be stored in a designated, secured area that was accessible only to authorized personnel.Observation on 05/07/2026 at 10:55 AM, of the facility's medication storage area, revealed five boxes of medication cards. Per observation, there were four cardboard boxes and one gray plastic tote sitting on the floor, unsecured, outside the locked medication storage area. In interview, at the time of observation, Registered Nurse (RN) 1 stated those containers had empty medication cards to be reviewed by the pharmacist. However, continued observation revealed 36 cards with pills remaining in them stored in the gray tote. Observation revealed the four cardboard boxes contained empty medication cards only. In continued interview, RN 1 stated she was unsure why those medications were stored in the gray tote, unsecured. She further stated she would need to defer that to the Director of Nursing (DON). During an interview with the DON on 05/07/2026 at 11:30 AM, the State Survey Agency (SSA) Surveyor made the DON aware of the concern regarding multiple medications being stored in the hallway, accessible to all residents, staff, and visitors. She then stated the boxes of medication cards should not have been sitting out unsecured. The DON further stated the medication cards should have been stored in the locked storage area. During an additional interview with the DON on 05/07/2026 at 2:59 PM, she stated, the boxes of medication cards found outside the storage room had been moved to a locked room after there were brought to her attention as a concern. She reported there were wanderers on the unit who could have pilfered through the box (gray tote) containing the medications and accessed those medications. The DON further stated her expectation was for all medications to be stored in a locked place. She additionally said she would educate her staff regarding proper medication storage.During an interview with the Administrator on 05/07/2026 at 4:26 PM, she stated the box (gray tote) of medications found in the hallway should have been returned to the pharmacy immediately. She further stated the facility did have some residents who wandered; however, did not generally get back to the area where the medications had been stored (unsecured).

Based on interviews and record review, it was determined the facility failed to provide the services of a Registered Nurse (RN) at least eight (8) consecutive hours a day, seven (7) days a week from 07/01/2023 through 09/30/2023. The findings include: Review of the facility's policy titled, Staffing Policy, revealed it was the policy of the Center to ensure that sufficient qualified nursing staff were available daily to meet residents needs for nursing care and in a manner and environment which promotes each resident's physical, mental and psycho-social well-being thus enhancing their quality of life. Staffing was determined within the facility based on work assignments designed to meet the needs of residents as determined by the resident assessment and individual plans of care. Review of the facility's July 2023 daily staffing sheets revealed the facility failed to have RN coverage for eight (8) consecutive hours in the facility on 07/01/2023, 07/02/2023, 07/08/2023, 07/09/2023, 07/15/2023, and 07/16/2023. Review of the facility's August 2023 daily staffing sheets dated 08/01/2023 through 08/20/2023, revealed there was documented RN coverage for eight consecutive hours each day. Review of September 2023 daily staffing sheets revealed there was no documented RN coverage on 09/06/2023, 09/07/2023, 09/09/2023, 09/23/2023, and 09/30/2023. In an interview with the Business Office Manager (BOM) on 02/15/2024 at 10:04 AM, she stated she was unaware that the facility had no RN coverage as the Administrator was an RN. The BOM was unaware that the Administrators hours were not reported as direct care hours. In an interview with the Director of Nursing (DON) on 02/15/2023 at 5:58 PM, she stated the facility did not currently have a dedicated RN to work the weekends. She stated she believed resident safety was ensured, as the Administrator was also an RN and lived onsite. In an interview with the Administrator, on 02/15/2024 at 6:15 PM, she stated she was the Administrator but also an RN. She stated she was aware that the facility had days with no RN on duty, but she was an RN and lived onsite. The Administrator stated she was unaware her hours in the facility did not count for the RN coverage. She stated the facility had difficulty with hiring RNs, but the DON was always on call to cover call ins.

Based on observations, interviews, and review of facility documents, it was determined the facility failed to store, label, and date food in accordance with professional standards for food service safety. The findings include: Review of a facility document titled, Labeling and Dating for Safe Storage of Food, dated 04/10/2023, revealed labeling and dating were critical in order to promote food safety. The use of use by dates would be reviewed. All products should be dated upon receipt. All products should be dated when opened, used by dates on all food once opened and stored under refrigeration. Observation of the kitchen on 02/14/2024 at 8:42 AM, revealed walk in cooler #1 contained a plastic container partially full of a brown substance that was not labeled or dated. Further observation revealed a container full of a yellow/orange substance not labeled or dated. Observation of the kitchen on 02/14/2024 at 8:48 AM, revealed walk in cooler #2 contained a tray containing forty-one (41) ten (10) ounce Styrofoam cups of various liquids that were not dated. In an interview with the Certified Dietary Manager on 02/14/2024 at 8:50 AM, she stated the brown substance was caramel sauce and the yellow/orange container was cheese sauce left over from a facility party. She further stated the tray of various liquids were from the supper meal the previous night. The CDM stated she would remove all the items from the coolers because they should be labeled and dated prior to storage.

Based on observations, interviews, and review of the facility policy, it was determined the facility failed to post staffing data for two (2) of the three (3) days of the survey. The findings include: Review of facility's policy titled, Staffing Policy, not dated, revealed the center would post the facility name, the current date, the Resident census, and the actual number of nursing staff on duty each shift daily. Included with this posting would be Registered Nurses, Licensed Practical Nurses, Medication Aids and Nursing Assistants directly responsible for patient care. The daily posting would be displayed in a public place, clearly visible where residents, staff and the general public may view it. Observation of the daily staffing posting on 02/13/2024 at 6:30 PM, revealed that the staffing posted for the 300 Hall, was dated 02/08/2024. Observation of the daily staffing posting on 02/14/2024 at 9:30 AM, revealed that the staffing posted for the 300 Hall, was unchanged and dated 02/08/2024. In an interview with the Director of Nursing (DON) on 02/15/2024 at 5:58 PM, she stated it was the responsibility of the night shift staff to update the white board for staffing. She stated the Administrator did the scheduling and posted the staffing sheets at the nurse's station. In an interview with the Administrator on 02/15/2024 at 6:15 PM, she stated she was aware that the white board had not been updated since 02/08/2024 and that it did not contain the correct information. She further stated it was the expectation that the daily staff postings would be accurate.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to investigate and control rash related infections for residents, and staff, to include tracking and trending rashes to identify possible communicable rashes before they can spread to other persons in the facility for two (2) of seven (7) sampled residents (Residents #4 and #6). The findings include: Review if the facility's policy, Infection Control, not dated, revealed it is the policy of the facility to provide a safe, sanitary, and comfortable environment. The facility will investigate, control, and attempt to prevent the development and transmission of infections. Protocol: 2. The objectives of our infection control policies and procedures are to: a) investigate, control, and prevent infections in the facility; b) maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c) establish guidelines to follow in the implementation of Isolation Precautions; d) maintain records of incidents and corrective actions related to infections; e) establish guidelines to follow in implementing Standard Precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. Review of the facility's timeline for skin rashes revealed Residents #4, and #6 who resided on the Infirmary Unit had ongoing skin rashes that had been treated but would continue to spread and not improve. 1. Review of the time line revealed Resident #4 had a rash ongoing since 04/2018. Observations of Resident #4 on 07/24/18 at 2:00 PM revealed the resident sitting up in wheelchair across from nursing desk scratching both arms and head; on 07/25/18 at 9:30 AM he/she was sitting in wheelchair at commons area of unit, scratching at the back of his/her neck, with white flaky particles noted on clothing, and both hands were dry. Observation of Resident #4's skin assessment performed by Registered Nurse (RN) #3, on 07/25/18 at 2:00 PM, revealed a red scattered rash to the forehead, face, back of neck, both breast, abdomen, and lower back. Additionally, pink colored scattered dry rash noted to posterior left leg at bend of knee. Further observation revealed the resident was scratching at back of neck, arms, and legs throughout the skin assessment. 2. Review of the time line revealed Resident #6 had a rash ongoing since 03/2018. Review of Resident #6's Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed Resident #6 was treated with [MEDICATION NAME] Cream 5% on 07/11/18 after three (3) flat rash areas were noted to the left breast and again with [MEDICATION NAME] Cream on 07/18/18 Observation of Resident #6 weekly skin assessment, on 07/25/18 at 9:40 AM, performed by RN #3 revealed (3) areas to right breast adjacent to right armpit which were red, circular, and raised, scattered red rash to abdomen below the umbilicus, and red whelped abrasion to right flank (below waist and above hip). Observation revealed Resident #6 scratching at areas below umbilicus, groin, and right flank; RN #3 applied Sarna lotion to skin as ordered for itching. Interview with Certified Nursing Assistant (CNA) #3, on 07/25/18 at 2:35 PM, revealed there have been consistent rash outbreaks amongst the residents and staff over the past year although, none of the residents' rashes was diagnosed as scabies. CNA #3 revealed she had a rash that the Physician diagnosed as scabies. Interview with LPN #1, on 07/25/18 at 4:50 PM, revealed she has been treated for [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2, on 07/26/18 at 10:20 AM, revealed Resident #6 was treated with [MEDICATION NAME] Cream for skin rash. She stated the skin rash improved after treated. Interview with RN #3, on 07/25/18 at 2:15 PM, revealed she was aware some residents in the Infirmary Unit had a rash. RN #3 stated she was not aware of any residents that had been diagnosed past or present with scabies. RN #3 revealed at least seven (7) residents had been treated for [REDACTED]. Interview with RN #1, on 07//25/18 at 11:05 AM, revealed she treated Resident #6 with [MEDICATION NAME] Cream on 07/11/18 and 07/18/18. RN #1 stated Resident #6 was not diagnosed with [REDACTED]. RN #1 revealed Resident #6's rash was minimal but the resident was consistently itching and scratching at his/her abdomen and chest. RN #1 stated, when a resident develops a rash, it is communicated to the Director of Nursing (DON) who in turn contacts the Physician. RN #1 revealed she was not aware if the Physician assessed the rash prior to ordering the [MEDICATION NAME] treatment. Interview with the DON, on 07/26/18 at 9:15 AM, revealed each resident with a skin rash in the facility have received treatment. The DON stated she is responsible for tracking and trending infections in the facility although the rash outbreak was not tracked nor trended. The DON further stated, there were similar characteristics in some of the rashes however, there was not a pattern identified. She further revealed she did not have any documentation of trending the skin rashes. When asked for list of all residents treated for [REDACTED]. Further interview revealed the Infirmary Unit census was thirty-six (36) residents and eleven (11) of the (36) have been treated for [REDACTED]. The DON would not reveal the number of employees who have been treated for [REDACTED]. Interview with the facility's Medical Director, on 07/26/18 at 12:08 PM, revealed eleven (11) residents and six (6) employees have been treated for [REDACTED]. The Medical Director stated, I have seen some rashes at the facility that were classic of scabies and were treated; and I have seen some cases that were misdiagnosed as scabies. Any residents and/or employees that are treated for [REDACTED]. He revealed he received a call from the DON on 07/11/18 and she described the rashes that Resident #6, had on his/her body and scratching. He stated he decided to be aggressive with treatment ([MEDICATION NAME]) due to the facility dealing with residents' and staff' rashes and the treatments by other providers. He stated staff were being told they had scabies and were not treated with appropriate doses and the rashes were coming back. He revealed he had never seen a spread of rash to staff until recently.

Based on interview, review of Emergency Drug Box List/ Reorder Forms, Emergency Drug Kit Sign out Sheets, and EDK Fax Forms; and facility policy review, it was determined the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, related to maintaining the par levels of one (1) medication (antibiotic) in the Emergency Drug Kit (EDK.) Observation of the Emergency Drug Kit (EDK) on [DATE], revealed established par levels had not been maintained and interviews revealed the Pharmacist had not visited the facility in months to replenish the stock. The findings include: Review of the facility policy titled, Medication Ordering and Receiving From Pharmacy, not dated, revealed emergency needs for medication are met by using the facility's approved medication supply or by special order from the provider pharmacy. If medications are used from the EDK, the nurse completes the emergency box usage form, faxes it to the pharmacy and places the completed sheet inside the box. The Fax serves as a notification to the pharmacy that the EDK Stock needs replacement. The EDK is maintained at a designated area, along with a list of supply contents posted on the emergency box. The kits are inventoried by the pharmacy consultant at least every thirty (30) days, for completeness and expiration of the contents. Review of the Emergency Drug Box List/ Reorder Form, revealed there was supposed to be four (4) [MEDICATION NAME] 250 milligrams in the EDK; however, observation of the EDK on [DATE] at 3:03 PM, with Licensed Practical Nurse (LPN) #5, revealed there was an empty container for [MEDICATION NAME]. Review if the Emergency Drug Kit Sign out Sheets and the EDK Fax Forms dating back to [DATE], revealed there was no evidence of how or when the [MEDICATION NAME] was used or what resident may have utilized the antibiotic. Interview with the Pharmacy Consultant on [DATE] at 3:58 PM, revealed she had not been to the facility in about four months as the previous DON told her they would fax in the orders and they could be replaced that way, instead of regular visits. The consultant stated she had not been made aware there were any problems with this process. Interview with the Director of Nursing (DON) on [DATE] at 3:48 PM, revealed the facility had the pharmacy consultant come out every once in a while to see if anything was expired, but normally the local pharmacy could be notified with any need and are on call ,[DATE]. The DON stated the pharmacist hated it when medications in the EDK expire and they lose the cost of the medication. Interview with the Administrator on [DATE] at 4:00 PM, revealed she was unaware there was a problem with the EDK and the established par levels were not in supply

Based on interview, and review of the facility policy, it was determined the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, related to proper dating of medications after opening. Audits of the medication carts on the skilled wing revealed several liquid medications had been opened and not dated after opening. Additionally, it was determined narcotics were not secured behind double locks for one (1) of four (4) medication carts. The findings include: Review of the facility policy titled, Administering Medications, not dated, revealed when the staff opened a multi-dose container of medication, they were to have placed the date on the container. Review of the facility policy titled, Medication Storage in the Facility, not dated, revealed Schedule II, III, IV, and V medications and other medications subject to abuse are stored under double lock. Observation of the medication pass on the 300 Wing Skilled areas on 05/02/18 at 5:10 PM, revealed six (6) bottles of [MEDICATION NAME] for six (6) different residents, one (1) bottle of [MEDICATION NAME] Tonic and [MEDICATION NAME]; and two (2) bottles of [MEDICATION NAME] Liquid, for two other residents, had not been dated when opened. Further observation revealed the narcotic box on the medication cart was not securely fastened to the narcotic drawer and had a false bottom, so that, when the narcotic box drawer was pulled all the way out, the narcotic box could easily be lifted out of the drawer and the narcotics would be left lying on the bottom tray of the drawer, easily available, without unlocking the box. Interview with Certified Medication Tech (CMT) #1, on 05/02/18 at 5:15 PM, revealed it was the facility policy to date the medications, when opening, yet she was unsure why this had not been followed. The CMT was not aware of the narcotics not being securely double locked and stated she never noticed this was even possible. Interview with the Director of Nursing (DON), on 05/03/18 at 9:20 AM, revealed she had the maintenance coordinator secure the box to the cart. Further interview with the DON on 05/04/18 at 3:48 PM, revealed she expected the staff to date liquid medications, as per the policy, but was not aware this had not been done and the staff were trained and aware of the policy. The DON also stated she had never seen or heard of this happening with a narcotic box. Interview with the Administrator on 05/04/18 at 4:00 PM, revealed she would have expected the liquid medications to have been dated when opened by the staff passing the medications and was not aware there was a problem and she also had not heard of a narcotic box being made in such a way.

Based on interview, record review, and review of the facility policy and procedure for Resident Abuse, Neglect, and Exploitation, it was determined the facility failed to implement the policy related to immediately reporting alleged exploitation of one (1) of nine (9) sampled residents to the Supervisor/Administrator (Resident #1). On 03/07/18 at approximately 11:00 PM, State Registered Nurse Aide (SRNA) #1 reported to Licensed Practical Nurse (LPN) #4 that she had pulled Resident #1 on to the floor and reported the resident had fallen to cause more work for the nurse because she would have to do neuro checks which included vital signs. However, LPN #4 did not report this information to the Administrator/Supervisor immediately per facility policy. LPN #4 reported the incident the next day (approximately sixteen (16) hours later) to her Supervisor/Administrator. The findings include: Review of the facility policy and procedure for Resident Abuse, Neglect, and Exploitation, dated 11/28/16 revealed, In our facility, we believe that it is each individual's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse, neglect, and exploitation by anyone including, but not limited to: facility staff, other residents, volunteers, consultants, contractors, or other agencies, family members, legal guardians, friends or other individuals. Any alleged incidences of abuse, neglect, and exploitation must be reported immediately to the appropriate supervisor and the Administrator of the facility must be notified without delay. Record review revealed the facility admitted Resident #1 on 08/18/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/03/18 revealed there was no Brief Interview of Mental Status attempted due to severe cognitive deficit. Review of an Abuse investigation completed by the facility revealed on 03/08/18 when LPN #4 came to work on the 3:00 PM-11:00 PM shift, she spoke with the Assistant Director of Nursing (ADON) to report a potential exploitation situation. She stated LPN #4 revealed SRNA #1 had told her on 03/07/18 that she had placed Resident #1 on the fall mat by the bed and told LPN #3 the resident had fallen so LPN #3 would have to do neuro checks and vital signs throughout the night. The ADON called the Director of Nursing (DON) who in turn, called the Administrator. Interview with LPN #4 on 05/04/18 at 9:21 AM revealed she was in the parking lot of the facility when SRNA #1 came up to her and told her she had placed Resident #1 on the floor so LPN #3 would have to do vital signs and neuro checks. She stated she knew she needed to report what SRNA #1 had revealed but decided to wait until the next day when she returned to work so she could have a face to face meeting with the DON and not a phone call. She revealed she thought she had twenty-four (24) hours instead of two (2) hours to report. Interview with ADON on 05/04/18 at 3:30 revealed LPN #4 came to her on 03/08/18 at 3:00 PM and reported the conversation she had with SRNA #1 on 03/07/18 regarding Resident #1. She stated she immediately called the DON. Interview with DON on 05/04/18 at 4:30 PM revealed LPN #4 should have followed the facility policy related to reporting abuse/ neglect, exploitation to the Administer/Supervisor immediately Interview with the Administrator on 05/03/18 at 5:15 PM revealed she had been called about the alleged abuse situation involving Resident #1 and SRNA #1 on 03/08/18 at approximately 3:30 PM. She stated LPN #4 should have followed the facility policy and reported the incident to the DON immediately.

Based on observation and interview, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible related contract workers left dry wall tools, materials and equipment unattended in a resident hallway where one (1) unsampled resident not in the selected sample of nine (9) residents (Unsampled Resident #12). On 05/03/18, observation revealed two contact workers left two (2) metal scaffolds, a large plastic yellow barrel with three (3) metal putty knifes in it and a open bag of dry wall powder in the hallway unattended on the floor with no staff or personnel monitoring it to ensure mobile residents (Resident #12) would not have access. The findings include: Interview with Maintenance Director on 5/3/18 at 3:03 PM, revealed the facility did not have any specific policy related to contract workers, expectations of or anything related to the use of contract workers and safety. Observation of Hallway #2 on the infirmary unit on 05/03/18 at 2:08 PM until 2:22 PM, revealed two (2) metal scaffolds, a large plastic yellow barrel with three (3) metal putty knifes in it and a open bag of dry wall powder in the hallway unattended on the floor with no staff or personnel monitoring it for approximately fourteen (14) minutes. Record review revealed the facility admitted Unsampled Resident #12 on 10/03/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Unsampled Resident #12 cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of one (1), which indicated the resident was not interviewable. Interview with Certified Medication Aide (CMA) #1 on 05/04/18 at 01:20 PM, revealed Unsampled Resident #12 moves in the wheelchair independently and moves up and down the halls on the infirmary unit. She stated Unsampled Resident #12 is cognitively impaired and would not be able to make appropriate decisions and know to stay away from dangerous items or materials. Interview with Certified Nurses Aide (CNA) on 5/4/18 at 2:40 PM, revealed Unsampled Resident #12 can propel his/herself while in the wheelchair up or down the hall by his/herself. Interview on 05/03/18 at 2:22 PM with Contract(NAME)#1, revealed he worked for a construction company and had been working at the facility on a project. He stated he was the one responsible for having left the tools, equipment and materials unattended while himself and the other contract worker went on break. He stated they went on break about 2:05 PM and had been gone until this time. He stated the facility had told them to make sure they do not leave any of their equipment, tools or materials unattended. He stated it was his fault that they left their stuff unattended. Interview with Contract(NAME)#2 on 5/3/18 at 2:24 PM, revealed he had been at the facility working with(NAME)#1 and it was not okay to leave their tools, equipment and material unattended. Interview with Maintenance Assistant #1 on 05/03/18 at 02:27 PM, revealed it is not appropriate for the carpenters to have left their tools, equipment and materials out unattended. Interview with Maintenance Director on 5/3/18 at 3:03 PM, revealed they expect any contract person's or carpenters to ensure they keep all their tools and equipment secure at all times. He stated the facility had not done any formal training with the contract workers related to safety and securing their tools, material and equipment. He revealed if the contract workers leave for a break or meal, he would expect the contractors or carpenters to ensure their tools, equipment and materials are out of a resident's access and secure. He stated it was not appropriate or safe for the two (2) workers to have left their tools, equipment and material unattended while they went to break. He stated the facility had put nothing in place to monitor the contract workers to ensure items were put away when went to lunch, breaks, and left for day. Interview with Director of Nursing (DON) on 05/03/18 at 02:25 PM, revealed it is unacceptable to leave tools, equipment and hazardous materials out unattended in a resident area where resident's may travel through.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure each resident received food served at the proper temperatures for the supper meal on 02/02/16 at 4:50 PM. Observation revealed the Dietary Aide served gravy at a temperature of one-hundred six (106) degrees and cole slaw at a temperature of forty-five (45) degrees. Review of the facility Census and Condition, dated 02/02/16, revealed there was seventeen (17) residents in the facility and they all received their meals from the kitchen. The findings include: Review of the facility's policy and procedure, titled Food Temperatures, not dated, revealed gravy should be served at greater than one-hundred and forty (140) degrees and cole slaw (hazardous salads) at less than forty-one (41) degrees. Observation of a Supper Meal, on 02/02/16 at 4:50 PM, revealed the dietary aide served gravy at a temperature of one-hundred six (106) degrees and cole slaw at a temperature of forty-five (45) degrees. Review of the Dietary Food Temperature log revealed gravy was served at a temperature of one-hundred six (106) degrees and cole slaw at a temperature of forty-five (45) degrees. Interviews with four (4) sampled residents ( Residents #1, #2, #3, and #5 and three (3) unsampled residents (Resident #B, #D, and #E), with a Brief Interview of Mental Status (BIMS) score between eight (8) and fifteen (15), on 02/02/16 at 5:30 PM, revealed the food tasted all right but could have been a little warmer. Interview with the Dietary Manager (DM) and Registered Dietitian (RD), on 02/03/16 at 2:07 PM, revealed they expected the gravy to have been taken back to the kitchen and re-heated prior to serving. In addition, they stated the cole slaw should have been made up earlier in the day which would have given it a chance to be colder at the time of service.

Based on observation, interview, review of the facility Census and Condition, and facility policy review, it was determined the facility failed to ensure food was stored under sanitary conditions. Review of the facility Census and Condition, dated 02/02/16 revealed there were seventeen (17) residents in the facility and they all received their meals from the kitchen. Observation during kitchen tour revealed items in the refrigerator not dated when opened and the night shift Dietary Cook leaving the tray line and returning to prepare food without changing her gloves and washing hands. The findings include: Review of the facility's policy and procedure titled, Food Storage, not dated, revealed, all food items were to be dated and labeled. 1. Observation during the initial tour of the kitchen, on 02/02/16 at 8:30 AM, revealed one (1) bottle of steak sauce and two (2) bottles of chocolate syrup opened and not dated as to when they were opened. 2. Observation of the tray line service during the lunch meal, on 02/03/16 at 11:15 AM, revealed the Dietary Cook mixing substances together in a bowl with gloved hands and then leaving the bowl to retrieve items from the refrigerator and returning to the bowl and mixing with her hands without changing her gloves or washing her hands. Interview with the Dietary Cook, on 02/03/16 at 2:07 PM, revealed she knew not to touch food with contaminated gloves and if she had to leave the area where she was preparing food, gloves should be changed and hands washed prior to returning to serving food. Interview with the Dietary Manager, on 02/03/16 at 2:07 PM, revealed she expected the staff to change gloves and to wash hands after leaving the tray line. She stated all staff was responsible for dating items when they were opened. Interview with the Registered Dietitian, on 02/03/16 at 2:07 PM, revealed she expected the staff that left the food prep area to change gloves and wash hands prior to returning to serving food. She stated all food items should be dated when opened. Interview with the Administrator, on 01/29/16 at 12:35 PM, revealed she expected staff to handle, label and store food per the facility's policy.

Based on interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determine the facility failed to ensure administration of medications was provided according to professional standards of quality for one (1) unsampled resident (Resident A). Certified Medication Tech (CMT) #1 failed to administer a medication to Unsampled Resident A at the right time according to the physician's orders [REDACTED].>The findings include: Review of the KBN AOS #14 Patient Care Orders, last revised 10/2010, revealed staff should administer medication and treatment as prescribed by the physician/advanced practice registered nurse which includes in the prescribed dose, route and frequency Record review revealed the facility admitted Unsampled Resident A on 01/16/09 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. However, observation of a medication pass on 02/02/16 at 4:30 PM revealed the CMT #1 administered the [MEDICATION NAME] at 4:30 PM. Interview with CMT #1, on 02/02/16 at 5:00 PM, revealed she was behind on her medication pass because she was being slowed down by the surveyor observing her. She stated she should have notified the charge nurse so he/she could notify the physician to find out when the medication should be given the next time. Interview with the Director of Nursing (DON), on 02/03/16 at 8:55 AM, revealed she expected the staff to administer medication per the physician orders. She stated if the medications were going to administered late, then the CMT should have told the charge nurse so he/she could notify the physician for guidance as to when the medication should be given again.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one (1) of eight (8) sampled residents (Resident #3). Registered Nurse (RN) #1 failed to wash her hands or use hand sanitizer after she removed the soiled dressing from Resident ' s #3 wound. Observation revealed RN #1 removed the contaminated gloves and then put on a pair of clean gloves without washing her hands or using hand sanitizer. She further failed to remove the contaminated gloves and wash her hands after completing the dressing change for Resident #3. RN #1 touched the residents adult brief, repositioned the residents clothing and linens all while wearing the contaminated gloves. The findings include: Review of the facility's policy titled Hand Hygiene, dated 03/31/04, revealed it is the policy of this home that all nursing personnel will use correct hand washing technique weather using soap and water or alcohol based hand rubs. This policy applies to all nursing personnel providing care. Hand washing is required after direct contact with resident, after removing all gloves, after contact with inanimate objects in the immediate vicinity of a resident. Review of the facility's policy titled Wound Care (undated), revealed the purpose of the policy was to provide guidelines for the care of wounds to promote healing. Steps in the procedure after removing dressing were to discard in the appropriate receptacle. Wash and dry hands thoroughly then put on new gloves. Further review revealed after completing the dressing change remove disposable gloves and discard into designated container. Wash and dry hands thoroughly, then reposition the bed covers. Record review the facility admitted Resident #3 to the infirmary on 04/08/15, with diagnoses, which included Anemia, Venous Insufficiency, Chronic Kidney Disease, and Moisture Related Skin Breakdown. Observation on 03/03/16 at 9:30 AM, revealed RN #1 providing wound care for Resident #3. Further observation revealed RN #1 removed the soil dressing from Resident #3's coccyx area, cleaned and dried the wound then removed the soiled gloves and immediately replaced them with another pair of clean gloves without washing her hands. RN #1 continued with the wound care and applied the treatment as ordered and reapplied the dressing while wearing the same pair of gloves. Further observation revealed RN #1 did not remove the contaminated gloves, but continued to assist Resident #3 with adult brief, replaced clothes and linens prior to removing the contaminated gloves. Interview with Registered Nurse ( RN #1) on 02/03/16 at 9:40 AM, revealed she was not aware she was required to wash her hands or use hand sanitizer after removing the dirty dressing, prior to putting on clean gloves. She further revealed she usually removes the dirty gloves as soon as she has completes the dressing change but just forgot today. Interview with Director of Nursing (DON), on 02/03/16 at 5:00 PM, revealed the nurses are educated to change gloves and use hand sanitizer or wash hands during the dressing removal process. She further revealed she expected the nurse to remove the contaminated gloves prior to cleaning up Resident#3, and most of the nurses have hand sanitizer in their pockets to use.

Based on observation, interview, and review of the facility policies and procedures, it was determined the facility failed to ensure food was stored, prepared and served under sanitary conditions. Observation during the survey revealed open, unlabeled milk containers, a build-up of frozen condensation in the walk-in freezer, as well as a build-up of frozen condensation in the chest freezer. Additionally, two (2)observations revealed a facility staff walking through the kitchen food preparation area without any form of hair restraint. The findings include: Review of the facility's policy, "Personal Hygiene", undated, revealed to wear a clean hat or other hair restraint. Hair must be appropriately restrained per State regulations. Head covering must be clean, and beards or any body hair that may be exposed (i.e., arms) must be covered. Review of the facility's policy, "Food Storage", undated, revealed to label and date all food items. Observation, on 03/18/15 at 8:00 AM, revealed two (2) open, partially used gallons of milk, without a label to indicate the date opened. Observation of the walk-in freezer revealed a two (2) to three (3) inch build-up of ice on the floor, located beneath the freezer fans, as well as a large build-up of ice on the ceiling of the walk-in freezer located in front of the fans. Further observation revealed the chest freezer was being utilized for ice cream, and miscellaneous food items were observed to have a large build-up ice on the sides of the chest freezer. Additional observation, on 03/18/15 at 8:15 AM, revealed a facility staff entered the kitchen, walked past the food preparation area without any type of hair restraint, and exited the kitchen through a second door. At 8:20 AM, the same facility staff re-entered the kitchen and walked through the kitchen, past the food preparation area a second time, without any type of hair restraint. Interview with the Dietary Manager, on 03/18/15 at 8:20 AM, revealed anyone who entered the facility kitchen should have a hair restraint in place. She stated facility staff walked through the kitchen area on multiple occasions without a hair restraint. Further interview with the Dietary Manager, on 03/18/15 at 8:30 AM, revealed the build-up of ice on the walk-in freezer floor and the ceiling had been a problem in the past and it was addressed. The Dietary Manager could not recall if anything was done at the time to correct the problem, or the date that someone had looked at it. She revealed she was responsible to ensure there was no build-up of ice in the chest freezer, and stated the freezer was not on the schedule for defrosting or cleaning. The Dietary Manager also revealed moisture dripping in the walk-in freezer could potentially drip on the food and was problematic.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to revise the care plan for one (1) of eight (8) sampled residents (Resident #2), after a significant weight loss. The findings include: Review of the facility's policy and procedure titled, "Comprehensive Care Plans", not dated, revealed the Comprehensive Care Plan was to include measurable objectives and timetables to meet the resident's medical and nursing needs. Further review revealed the care plans are revised as changes in the resident's condition dictates. Record review revealed the facility admitted Resident #2 on 02/12/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/20/14, revealed the facility had assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident was not interviewable. Review of the facility's "Vital Sign and Weight Flow Sheet", not dated, revealed Resident #2's weight was noted on 02/07/15 to be 117 pounds, and on 02/14/15 Resident #2's weight was noted to be 111 pounds, with a loss of six (6) pounds in one (1) week. Review of the facility's "Nutritional Progress Note", dated 03/12/15, revealed Resident #2's weight was 105 pounds. Further review revealed a significant weight loss was identified and a House Supplement (nutritional supplement) was added at that time. Review of the Comprehensive Care Plan, dated 03/17/15, revealed the facility assessed Resident #2 at risk for unintended weight loss; however, there was no documented evidence the care plan was updated until 03/09/15, when a new intervention was added for Speech and Occupational Therapy Screenings. Interview with Licensed Practical Nurse (LPN) #1, on 03/19/15 at 10:35 AM, revealed she did not remember noting Resident #2's weight loss on 02/14/15; however, she stated she should have immediately notified the resident's physician and family and notified the Director of Nursing (DON). She also stated the Registered Dietitian should have been notified and a new intervention added to the resident's Comprehensive Care Plan. Interview with the Registered Dietitian, on 03/19/15 at 9:30 AM, revealed Resident #2 had a significant weight loss of six (6) pounds from 02/07/15-02/14/15 which was a five percent (5%) weight loss in one (1) week. She stated any weight loss of two percent (2%) or greater in one (1) week would be considered a significant weight loss. She further stated the physician and the resident's family should have been notified and an intervention should have immediately been put in to place to prevent further weight loss. Interview with the Minimum Data Set (MDS) Coordinator, on 03/19/15 at 10:15 AM, revealed it was her responsibility to review the weekly weights and report any noted weight loss to the DON. She further stated it was her responsibility to update the Comprehensive Care Plan with new interventions when weight loss was identified. She stated she was not sure what happened. Interview with the DON, on 03/19/15 at 10:00 AM, revealed any identified weight loss should be immediately reported to her. She further stated the Registered Dietitian, the resident's physician, and the resident's family would be notified and the Plan of Care would be updated per the Dietitian's and physician's recommendations.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure residents maintained his/her body weight for one (1) of eight (8) sampled residents (Resident #2). Resident #2 sustained a weight loss of six (6) pounds resulting in a five percent (5%) weight loss in one (1) week from 02/07/15 through 02/14/15, without consistent assessment and intervention until the resident's weight was stable. The findings include: Review of the facility's policy and procedure titled, "Weights", dated 01/2014, revealed its policy was to monitor residents' weights. Further review revealed when a significant weight loss is identified, the Primary Care Physician and the Dietitian are to be consulted. Record review revealed the facility admitted Resident #2 on 02/12/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/20/14, revealed the facility had assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) indicating the resident was not interviewable. Review of the facility's "Vital Sign and Weight Flow Sheet", not dated, revealed Resident #2's weight was noted on 02/07/15 to be 117 pounds and on 02/14/15 Resident #2's weight was noted to be 111 pounds, with a loss of six (6) pounds in one (1) week. Review of the facility's "Nutritional Progress Note", dated 03/12/15, revealed Resident #2's weight was 105 pounds. Further review revealed a House Supplement (nutritional supplement) was added at that time. Interview with Licensed Practical Nurse (LPN) #1, on 03/19/15 at 10:35 AM, revealed she did not remember noting Resident #2's weight loss on 02/14/15; however, she stated she should have immediately notified the resident's physician and family and notified the Director of Nursing (DON). She also stated the Registered Dietitian should have been notified and a new intervention added to the resident's plan of care. Interview with the Registered Dietitian, on 03/19/15 at 9:30 AM, revealed Resident #2 had a significant weight loss of six (6) pounds from 02/07/15-02/14/15, which was a five percent (5%) weight loss in one (1) week. She stated any weight loss of two percent (2%) or greater in one (1) week would be considered a significant weight loss. She further stated the physician and the resident's family should have been notified and an intervention should have immediately been put in to place to prevent further weight loss. Interview with the DON, on 03/19/15 at 10:00 AM, revealed any identified weight loss should be immediately reported to her. She further stated the Registered Dietitian, the resident's physician, and the resident's family should be notified and the Plan of Care should be updated per the Dietitian's and physician's recommendations.

Based on interview, review of a video recording, record review and review of the facility's policy and procedure, it was determined the facility failed to have an effective system in place to ensure two (2) of nine (9) sampled residents (Residents #1 and #4) were free from abuse. Licensed Practical Nurse (LPN) #1 was video recorded via cellular phone, by Certified Nurse Aide (CNA) #1, on 04/07/14. The video recording revealed LPN #1 and Resident #1 were sitting at the Nurse's Station. Staff had placed three (3) over the bed tables around the resident to prevent him/her from wandering. LPN #1 was observed calling the resident an inappropriate name, pointing and shaking her finger at the resident, and talking to the resident in a commanding tone for approximately four (4) minutes. Resident #1 was audibly crying. Further review revealed there were three (3) staff members, CNA #1, CNA #2 and CNA #3, who observed this behavior, but failed to intervene or protect this resident and other residents by reporting the incident immediately to the Administration. Additionally, on 05/01/14 at 7:30 PM, CNA #5 observed Certified Medication Technician (CMT#1) grab Resident #4's hands tightly and hold the resident's hands in his/her lap. CMT #1 and LPN #3 then wheeled the resident backwards down the entire length of the hallway to the resident's room in a wheelchair. Once in the room, CMT #1 roughly removed Resident #4's sweater, jerked the wheelchair backward causing the resident to become suspended, by the soft belt restraint, above the fall mat in his/her room. CMT#1 then lifted Resident #4 from the wheelchair and "flung" him/her on the side of the bed. CNA #5 and LPN #1 failed to intervene or report this incident immediately to Administration. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 05/01/14 and was determined to exist on 04/07/14. The facility was notified of the Immediate Jeopardy on 05/01/14. The findings include: Review of the facility's "Resident Safe Environment" policy and procedures, (not dated), revealed each resident has the right to be free from verbal, physical, sexual, and mental harassment or abuse. The policy included the following definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish; Verbal Abuse - any use of oral, gestured, language that includes disparaging and derogatory terms to residents regardless of their ability to comprehend; Physical Abuse - as controlling behavior through corporal punishment; and Mental Abuse: as harassment, threats of punishment or deprivation. Any alleged incidents of abuse, neglect, or exploitation must be reported immediately to the appropriate supervisor; the Administrator of the facility must be immediately notified. 1. Record review revealed the facility admitted Resident #1 on 05/09/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/13, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. On 04/29/14, at 9:37 AM, review of the cellular phone video recording, dated 04/07/14 at approximately 3:00 AM, revealed Resident #1 was sitting at the Nurse's Station with three (3) over the bed tables placed around the resident to prevent him/her from wandering. LPN #1 was observed on the video calling Resident #1 "a brat", and telling the resident to "sit down" in a commanding voice repeatedly for approximately four (4) minutes. Resident #1 was audibly crying. Further review revealed two (2) other staff members, CNA #1 and CNA #2, who were partially visible and, the voice of a third staff member (identified by the Director of Nursing as CNA #3). The three (3) CNAs observed LPN #1 blocking Resident #1 in the Nurse's Station and heard the verbal remarks made to Resident #1 by LPN #1. Interviews with CNA #1, CNA #2 and CNA #3, on 04/29/14 at 2:45 PM and 3:10 PM; and, on 04/30/14 at 9:05 AM respectively, revealed they observed LPN #1 blocking the resident in the Nurse's Station so he/she could not wander on 04/07/14. CNA #1 and CNA #3 stated the LPN called the resident "a brat" and kept telling the resident repeatedly to "sit down". The CNAs stated they were intimidated by the LPN and she treated them like she was a "Drill Sergeant". Further interview with the CNAs revealed LPN #1 had previously told them to sit with Resident #1 and block him/her from walking freely on numerous occasions. The CNAs stated they did not report any of the incidents because of fear of retaliation by the LPN. CNA #1 stated she waited and reported the incident on 04/08/14 when the LPN was not at work. Interview with the Director of Nursing, on 04/29/14 at 9:37 AM, revealed she was not made aware of the video recording and the alleged abuse until 04/08/14 around 11:00 AM. She stated CNA #1 reported the incident and made the video recording. Further interview revealed the video recording lasted several minutes but the incident actually occurred over several hours. The DON stated the CNAs should have called the Administrator or the Assistant Director of Nursing immediately as they live in the facility. 2. Record review revealed the facility admitted Resident #4 on 01/20/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/18/14, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Interview with CNA #5, on 05/06/14 at 3:47 PM, revealed she witnessed CMT #1 and LPN #3 mistreat Resident #4 on 05/01/14 at approximately 7:30 PM. CNA #5 stated she saw CMT #1 grasp Resident #4's hands tightly and cross the resident's hands across his/her lap as LPN #3 pulled the resident's wheelchair backwards down the length of the hall taking Resident#1 into his/her room. CNA #5 revealed she observed CMT #1 roughly remove Resident #4's sweater and pull the wheelchair from under Resident #4 causing the resident to be suspended above the fall mat in his/her room. CMT#1 then roughly lifted Resident #4 from the wheelchair and "flung" him/her on the side of the bed. CNA #5 stated LPN #3 and she witnessed the incident; however, neither of them reported CMT #1's behavior to administration until the end of the shift at 10:30 PM when CNA #5 reported the incident to the DON. The CNA stated she waited for LPN #3 to report the incident; but when the LPN had not reported the incident by the end of the shift, she called the DON. Interview with LPN #3, on 05/07/14 at 1:50 PM, revealed on 05/01/14 at approximately 7:30 PM, Resident #4 was in the wrong room going through another resident's drawers. The LPN stated she attempted to redirect the resident but the resident began screaming. LPN #3 stated CMT #1 then came into the hallway and "pried the resident's hands off the wheels of the wheelchair and grasped them tightly and crossed them across the resident's lap." Further interview revealed she pulled Resident #4 backwards down the hallway and into the resident's room. LPN #3 recalled CMT #1 pulling Resident #4's sweater off over his/her head roughly and lifted the resident and put him/her on the bedside. LPN #3 stated, "It was shift change before I realized it and I did not report the incident." When LPN #3 was asked why she did not report the incident she stated, "I just didn't". The LPN stated she did not think her pulling the resident backwards down the hallway and allowing CMT #1 to roughly handle the resident as abusive behavior. Telephone interview with CMT #1, on 05/07/14 at 2:45 PM, revealed she was driving and could not talk at the time; however, she had typed a statement for the DON and stated the Surveyor could review the typed statement. Review of the typed statement signed by CMT #1, revealed Resident #4 was upset and was wheeling towards the wrong room and became very angry and was yelling at her. The CMT documented she called for LPN #3 to come to assist her and wheeled the resident to his/her room at which time the resident was kicking and screaming at her. The documentation revealed she pulled Resident #4's sweater off over his/her head; however, she did not feel she was rough. She then pulled the wheelchair at which time Resident #4 slid out of the chair putting pressure on his/her ribs with the soft seat belt. She documented she then picked Resident #4 up and sat him/her on the bedside. Further review revealed she had documented that she felt frustrated with Resident #4's behavior and left the room at that time. Interview with CMT #1, on 05/07/14 at 3:08 PM, revealed she confirmed the written statement read aloud to her. She further stated she did not feel she was rough with the resident. Interview with the Administrator and DON, on 05/06/14 at 2:45 PM, revealed they were both in the building when this incident occurred and the CNA should have reported it immediately. Further interview with the DON, on 05/07/14 at 3:15 PM, revealed she expected staff to redirect Resident #4 when he/she went into another resident's room and the staff should wheel the wheelchairs in a forward motion unless "they have to pull a wheelchair backwards through a doorway threshold. **The facility implemented the following actions to remove the Immediate Jeopardy: On 04/08/14, the facility suspended, then terminated LPN #1. The incident involving LPN #1 was then reported to the Kentucky Board of Nursing by the facility's DON. On 04/08/14 and 05/05/14, the Assistant Director of Nursing (ADON) conducted physical assessments on all the non-interviewable residents for signs/symptoms of possible abuse and interviews on all interviewable residents; no injuries were found. Further on 05/02/14, the ADON conducted interviews on all interviewable residents (those with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher to identify concerns related to care or any staff member, or events involving possible mistreatment by the staff or others with no concerns identified. The Nurse Care Plans for all residents were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 04/08/14 and repeated the interviews on 05/05/14 as education and re-education and training as part of their in-service training on the facility's abuse policy. Time cards were removed from the clock-in area and were not issued to the employees until the re-education was completed. Quality Assurance (QA) monitors began on 05/05/14 and included all facility staff and Continuous Quality Improvement (CQI) indicators for monitoring compliance with Care Planning to be conducted monthly for six (6) months beginning one month from 05/06/14 then quarterly thereafter under the supervision of the DON. Audits to be reported to the QA committee and a threshold of compliance is referenced as no abusive situations or reports. Compliance rounds are to be conducted weekly by the Administrator nursing staff to ensure compliance with resident care interventions being provided in accordance with the care plan. The State Agency validated the Corrective Action taken by the facility as follows: Interview on 05/22/14 at 4:00 PM with the Administrator revealed she was aware the Director of Nursing (DON) reported LPN #1's abusive behavior to the Kentucky Board of Nursing (KBN) on 05/02/14. Further interview on 05/22/14 at 4:00 PM with the Administrator revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14; LPN #3 is not eligible for rehire. CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility according to the Administrator. Additionally, interview on 05/22/14 at 4:00 PM with the Administrator revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administrator in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Interview on 05/22/14 at 4:30 PM with the Assistant Director of Nursing (ADON) revealed she was aware the DON reported LPN #1's abusive behavior to the KBN on 05/02/14. Further interview on 05/22/14 at 4:30 PM with the ADON revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14 and is not eligible for rehire; further CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility. Additionally, interview on 05/22/14 at 4:30 PM with the ADON revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administration in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Record review on 05/22/14 at 5:10 PM revealed an Employee Exit Interview dated 04/16/14 that shows LPN #1 was terminated on 04/16/14 and is not eligible for rehire. Further record review revealed LPN #3 and CMT #1 were suspended on 05/01/14 and 05/02/14 respectively, and then employment from the facility was terminated on 05/12/14 and neither are eligible for rehire at the facility. Additionally; CNA #1, CNA #2, CNA #3 received final written warnings and any future infraction will result in termination of employment at the facility, CNA #5 received counseling related to the reporting of abuse, neglect or mistreatment of [REDACTED]. Interview on 05/22/14 at 4:00 PM with the Administrator revealed she had oversight and that the ADON had conducted physical assessments and individually interviewed all residents of the Skilled Nursing Facility (SNF) on 04/08/14 and no findings of abuse were identified. Additionally she stated the ADON conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Interview on 05/22/14 at 4:30 PM with the ADON revealed she conducted physical assessments and individually interviewed all residents of the SNF on 04/08/14 and no findings of abuse were identified. Additionally she states she conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Record review on 05/12/14 at 3:00 PM revealed the physical assessments and the interviews with all residents of the SNF were conducted and recorded by the ADON and that no concerns were identified. Interview on 05/07/14 at 8:15 AM with the MDS Coordinator, who is a Registered Nurse (RN) revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the "Sisters". Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters, further stating the abuse hotline number was posted beside the time clock. Interview on 05/07/14 at 8:40 AM with a Housekeeper revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14. Her signature was noted on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go higher up or notify the DON or one of the Sisters. Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/22/14 at 5:29 PM with RN #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go to a higher up and notify the DON or one of the Sisters. She stated the primary concern was to keep the resident safe and remove the alleged perpetrator from the building immediately, "it's not just that we hear about abuse and have inservices on them, if you have a gut feeling something is wrong you do something about it." Interview on 05/07/14 at 5:45 PM with CNA #12 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" , or notify the DON or one of the Sisters. She further stated, "We have in-services and meetings frequently it seems, several times since I came seven (7) months ago, it's like fire and severe weather drills you should know what to do, wrong is wrong, report it immediately. Go to a nurse, if it's a nurse call the ADON or the DON and there's the numbers by the time clock for the Hotline if you need it." Interview on 05/22/14 at 5:50 PM with CMT #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON, or one of the Sisters. Interview on 05/22/14 at 6:00 PM with CNA #11 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety, abuse or mistreatment of [REDACTED]. She further stated they gave us all a sheet with their numbers on it so we can call them anytime we need to, as well. The Sisters have beepers if we need them. Interview on 05/07/14 at 6:05 PM with CNA #13 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/07/14 at 6:15 PM with a Dietary Staff Member revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/06/14 at 3:45 PM with the DON revealed she assigned the MDS Coordinator to review all residents' care plans on 04/11/14 and 05/05/14 for appropriateness, applicable problems, goals and interventions or approaches. The Nurse's Care Plans were reviewed and updated every quarter according to the resident's date their Minimum Data Set (MDS) was completed. Interview on 05/06/14 at 2:40 PM with the MDS Coordinator/RN revealed she conducted the review and update of the care plans. She stated usually this was an ongoing process, "I am out here with the residents and staff talking to the residents and we all talk about what is appropriate for whom and I update the care plans every third month, they reflect the MDS, and the CNA's care plan reflects the Nurse's Care Plan. We all give input and if we see any inconsistencies with the resident's ability we notify Sister, the ADON. Interview on 05/12/14 at 2:40 PM with LPN #2 revealed she was familiar with the review and update of the care plans. She stated the MDS Coordinator usually updates them every month. LPN #2 stated the MDS Coordinator was out on the Unit talking to the residents and staff. Interview on 05/12/14 at 4:55 PM with RN #1 revealed she recalled all staff was verbally reminded of the importance of following each resident's care plan. An example was voiced of walking with the resident if that is what the care plan indicated, if we don't see that it is followed we are not doing the right nursing care. As an RN, "I must see that the care plans are followed for the resident's well being." Interview on 05/22/14 at 5:29 PM with RN #2 revealed she has worked in the facility for one (1) month and was familiar with the review and update of the care plans. She stated the MDS Coordinator usually does that every so often. She further stated the MDS Coordinator was out on the Unit talking to the residents and staff. We all give input and if we see any inconsistencies we notify "Sister, the ADON". Review on 04/30/14 at 4:00 PM revealed in-service logs entitled "Resident safe Environment" and staff roster with signatures indicating attendance, dated 04/11/14. This inservice covered wheelchair safety, stress, burn-out, coping, gait belt use, oral care, cell phone use; and, abuse inservice signatures which indicated ninety- four (94) staff members attended the in-service between 04/11/14 and 04/14/14. Review on 05/12/14 of the in-service logs, dated 05/05/14, revealed all staff was inserviced related to abuse, neglect, recognizing and reporting signs of stress and burn-out, and following the plan of care. On 05/12/14 at 2:10 PM, CNA #9 verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. Interview on 05/12/14 at 2:17 PM with CNA #10; and at 2:40 PM with LPN #4, revealed they had received the in-service education on 05/02/14 by the ADON and they were aware of the signs/symptoms of abuse. The training also included to report to a supervisor immediately any allegation or witnessed abusive situations and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. On 05/12/14 at 2:45 PM, a housekeeper verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. On 05/12/14 at 4:55 PM, RN #1; on 05/22/14 at 5:29 PM with RN #2, and at 5:50 PM with CMT #2 verified through interview that they had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings. The inservice also included caregiver stress and signs of burn-out, and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. Interview on 05/22/14 at 5:55 PM with CNA #11 revealed she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the Nuns even to the point of interrupting prayer. She stated, "I would get a Sister because I feel like we should treat these people like they are our grandparents and you want your grandparents treated well." On 05/22/14 at 5:45 PM, CNA #12 verified through interview that she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the nuns even to the point of interrupting prayer."If it's wrong it's wrong, you can't let somebody get away with treating somebody mean you got to tell someone." Record review on 05/22/14 at 6:00 PM revealed the abuse allegations, the investigations, and the action plan was reviewed. Further review of a form entitled Continuous Quality Improvement; the Indicator: Knowledge and Compliance of Abuse and Reporting Policy; Recognizing Stress and Burn-out revealed one-hundred-seven (107) (all the facility staff) staff members received the re-education and in-service training and signed the rosters, their time-cards were held until their signatures were obtained in statement of participation. Through explanation by the ADON, random employees were asked Criteria/Question such as: stating the chain of command, know when to report, Identifies signs/symptoms of self stress and self burnout, names of coping strategies, know where to find contact numbers for reporting abuse. Each department will conduct these compliance rounds weekly and calculate the percentage of compliance. This will be conducted under the supervision of the DON and results will be reported to the QA committee. If an acceptable threshold of compliance is not achieved the DON will develop and oversee a corrective action. Compliance rounds are conducted weekly by the Administrative nursing staff to determine that resident care interventions are being provided in accordance with the care plan. Interview on 05/22/14 at 6:15 PM with the Medical Director revealed he was informed of the timing for the QA Committee meetings and he had attended the primary discussion with the Administrator, DON and ADON on 05/06/14. Further interview revealed he felt the facility was taking responsibility and being proactive with the QA plan they have put in place.

Based on interview, review of the phone video recording, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure staff reported observed incidents of abuse for two (2) of nine (9) sampled residents (Resident #1 and Resident #4), immediately to the Administration of the facility. Review of a cellular phone video recording revealed on 04/07/14 at approximately 3:00 AM, Licensed Practical Nurse (LPN) #1 had Resident #1 sitting in the Nurse's Station with over the bed tables placed around the resident to prevent him/her from wandering. LPN #1 was calling Resident #1 "a Brat", and pointing and shaking her finger at the resident and telling the resident to "sit down" in a commanding tone for approximately four (4) minutes. Resident #1 was audibly crying. Further review revealed there were two (2) other staff members (Certified Nurse Aides (CNA) #1 and CNA #2) who were partially visible and the voice of a third staff member (identified by the Director of Nursing {DON} as CNA #3). The three (3) CNAs observed LPN #1 blocking Resident #1 in the Nurse's Station and heard the verbal remarks made to the resident by LPN #1. However, the CNAs failed to report the mistreatment of [REDACTED]. Additionally, on 05/01/14 at 7:30 PM, CNA #5 observed Certified Medication Technician (CMT#1) grab Resident #4's hands tightly and hold the resident's hands in his/her lap. CMT #1 and LPN #3 then wheeled the resident backwards down the hallway to the his/her room. Once in the room, CMT #1 removed Resident #4's sweater roughly and then pulled the wheelchair from under Resident #4 causing him/her to be suspended above the fall mat in his/her room. CMT#1 then roughly lifted Resident #4 from the wheelchair and "flung" him/her on the side of the bed. LPN #3 and CNA #5 both observed CMT #1's treatment of [REDACTED]. The facility's failure to ensure staff reported observed incidents of abuse to the Administration immediately has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 05/01/14 and determined to exist on 04/07/14. The facility was notified of the Immediate Jeopardy on 05/01/14. The findings include: Review of the facility's "Resident Safe Environment" policy and procedures, (not dated), revealed each resident has the right to be free from verbal, physical, sexual, and mental harassment or abuse. The policy included the following definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish; Verbal Abuse - any use of oral, gestured, language that includes disparaging and derogatory terms to residents regardless of their ability to comprehend; Physical Abuse - as controlling behavior through corporal punishment; and Mental Abuse: as harassment, threats of punishment or deprivation. Any alleged incidents of abuse, neglect, or exploitation must be reported immediately to the appropriate supervisor; the Administrator of the facility must be immediately notified. 1. Record review revealed the facility admitted Resident #1, on 05/09/13, with [DIAGNOSES REDACTED]. Review of the cellular phone video recording, on 04/29/14 at 9:37 AM, revealed on 04/07/14 at approximately 3:00 AM, Resident #1 was sitting at the Nurse's Station with over the bed tables placed around him/her to prevent him/her from wandering. LPN #1 kept telling Resident #1 to "sit down" in a commanding voice and called Resident #1 "a brat", the LPN was exhibiting this behavior for four (4) minutes. Resident #1 could be heard crying. Further review revealed two (2) other staff members (CNA #1 and CNA #2), who were partially visible; and the voice of CNA #3 could be heard. The three (3) CNAs observed LPN #1 blocking Resident #1 in the Nurse's Station and heard the verbal remarks made to Resident #1 by LPN #1; however, no one immediately reported this to Administration. Interviews on 04/29/14 at 2:45 PM and 3:10 PM; and, on 04/30/14 at 9:05 AM respectively, with CNA #1, CNA #2, and CNA #3 revealed LPN #1 was blocking the resident in the Nurse's Station with over the bed tables so the resident could not wander on 04/07/14. CNA #1 and CNA #3 further stated the LPN was calling Resident #1 "a brat" and told the resident repeatedly to "sit down". All three (3) CNAs stated they were intimidated by LPN #1,as she treated them like she was a "Drill Sergeant". The CNAs stated LPN #1 had them sit with Resident #1 and block him/her from walking freely on numerous occasions. They stated they feared LPN #1 would retaliate if they reported any of the incidents. CNA #1 stated she waited until the LPN was not in the building then reported the incident to the DON. 2. Record review revealed the facility admitted Resident #4 on 01/20/14 with [DIAGNOSES REDACTED]. Interview, on 05/06/14 at 3:47 PM with CNA #5, revealed she witnessed CMT #1 and LPN #3 mistreat Resident #4 on 05/01/14 around 7:30 PM. CNA #5 stated she saw CMT #1 grasp Resident #1's hands tightly and cross them across the resident's lap as LPN #1 pulled his/her wheelchair backwards down the hallway taking Resident#1 into his/her room. CNA #5 stated she saw CMT #1 roughly remove Resident #1's sweater and pull the wheelchair from under Resident#1 causing the resident to be suspended above the fall mat in his/her room. In addition, CNA #5 stated CMT #1 roughly lifted Resident #1 from the wheelchair and "flung" him/her on the side of the bed. CNA #5 stated she did not report the incident to the administration of the facility until the end of the shift at 10:30 PM. The CNA stated she was waiting for LPN #3 to report the incident but when the LPN had not reported the incident by the end of the shift, she called the DON. Interview, on 05/07/14 at 1:50 PM with LPN #3, revealed on 05/01/14 at 7:30 PM she saw Resident #4 in the wrong room going through another resident's drawers. The LPN stated she redirected the resident but the resident began screaming. LPN #3 revealed CMT #1 then came up to the resident and "pried the resident's hands off the wheels of the wheelchair, grasped them tightly and crossed them across the resident's lap." Further interview with LPN #3 revealed she pulled Resident #4 backwards down the hallway into Resident #4's room. LPN #3 stated CMT #1 then pulled Resident #4's sweater off over his/her head roughly and lifted the resident and put him/her on the bedside. The LPN stated "It was shift change before I realized it and I did not report the incident." Interview with the Administrator and DON, on 04/29/14 at 9:37 AM and on 05/06/14 at 2:45 PM, revealed the staff who witnessed these incidents should have reported the mistreatment of [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 04/08/14, the facility suspended, then terminated LPN #1. The incident involving LPN #1 was then reported to the Kentucky Board of Nursing by the facility's DON. On 04/08/14 and 05/05/14, the Assistant Director of Nursing (ADON) conducted physical assessments on all the non-interviewable residents for signs/symptoms of possible abuse and interviews on all interviewable residents; no injuries were found. Further on 05/02/14, the ADON conducted interviews on all interviewable residents (those with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher to identify concerns related to care or any staff member, or events involving possible mistreatment by the staff or others with no concerns identified. The Nurse Care Plans for all residents were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 04/08/14 and repeated the interviews on 05/05/14 as education and re-education and training as part of their in-service training on the facility's abuse policy. Time cards were removed from the clock-in area and were not issued to the employees until the re-education was completed. Quality Assurance (QA) monitors began on 05/05/14 and included all facility staff and Continuous Quality Improvement (CQI) indicators for monitoring compliance with Care Planning to be conducted monthly for six (6) months beginning one month from 05/06/14 then quarterly thereafter under the supervision of the DON. Audits to be reported to the QA committee and a threshold of compliance is referenced as no abusive situations or reports. Compliance rounds are to be conducted weekly by the Administrator nursing staff to ensure compliance with resident care interventions being provided in accordance with the care plan. The State Agency validated the Corrective Action taken by the facility as follows: Interview on 05/22/14 at 4:00 PM with the Administrator revealed she was aware the Director of Nursing (DON) reported LPN #1's abusive behavior to the Kentucky Board of Nursing (KBN) on 05/02/14. Further interview on 05/22/14 at 4:00 PM with the Administrator revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14; LPN #3 is not eligible for rehire. CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility according to the Administrator. Additionally, interview on 05/22/14 at 4:00 PM with the Administrator revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administrator in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Interview on 05/22/14 at 4:30 PM with the Assistant Director of Nursing (ADON) revealed she was aware the DON reported LPN #1's abusive behavior to the KBN on 05/02/14. Further interview on 05/22/14 at 4:30 PM with the ADON revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14 and is not eligible for rehire; further CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility. Additionally, interview on 05/22/14 at 4:30 PM with the ADON revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administration in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Record review on 05/22/14 at 5:10 PM revealed an Employee Exit Interview dated 04/16/14 that shows LPN #1 was terminated on 04/16/14 and is not eligible for rehire. Further record review revealed LPN #3 and CMT #1 were suspended on 05/01/14 and 05/02/14 respectively, and then employment from the facility was terminated on 05/12/14 and neither are eligible for rehire at the facility. Additionally; CNA #1, CNA #2, CNA #3 received final written warnings and any future infraction will result in termination of employment at the facility, CNA #5 received counseling related to the reporting of abuse, neglect or mistreatment of [REDACTED]. Interview on 05/22/14 at 4:00 PM with the Administrator revealed she had oversight and that the ADON had conducted physical assessments and individually interviewed all residents of the Skilled Nursing Facility (SNF) on 04/08/14 and no findings of abuse were identified. Additionally she stated the ADON conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Interview on 05/22/14 at 4:30 PM with the ADON revealed she conducted physical assessments and individually interviewed all residents of the SNF on 04/08/14 and no findings of abuse were identified. Additionally she states she conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Record review on 05/12/14 at 3:00 PM revealed the physical assessments and the interviews with all residents of the SNF were conducted and recorded by the ADON and that no concerns were identified. Interview on 05/07/14 at 8:15 AM with the MDS Coordinator, who is a Registered Nurse (RN) revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the "Sisters". Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters, further stating the abuse hotline number was posted beside the time clock. Interview on 05/07/14 at 8:40 AM with a Housekeeper revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14. Her signature was noted on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go higher up or notify the DON or one of the Sisters. Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/22/14 at 5:29 PM with RN #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go to a higher up and notify the DON or one of the Sisters. She stated the primary concern was to keep the resident safe and remove the alleged perpetrator from the building immediately, "it's not just that we hear about abuse and have inservices on them, if you have a gut feeling something is wrong you do something about it." Interview on 05/07/14 at 5:45 PM with CNA #12 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" , or notify the DON or one of the Sisters. She further stated, "We have in-services and meetings frequently it seems, several times since I came seven (7) months ago, it's like fire and severe weather drills you should know what to do, wrong is wrong, report it immediately. Go to a nurse, if it's a nurse call the ADON or the DON and there's the numbers by the time clock for the Hotline if you need it." Interview on 05/22/14 at 5:50 PM with CMT #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON, or one of the Sisters. Interview on 05/22/14 at 6:00 PM with CNA #11 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety, abuse or mistreatment of [REDACTED]. She further stated they gave us all a sheet with their numbers on it so we can call them anytime we need to, as well. The Sisters have beepers if we need them. Interview on 05/07/14 at 6:05 PM with CNA #13 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/07/14 at 6:15 PM with a Dietary Staff Member revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/06/14 at 3:45 PM with the DON revealed she assigned the MDS Coordinator to review all residents' care plans on 04/11/14 and 05/05/14 for appropriateness, applicable problems, goals and interventions or approaches. The Nurse's Care Plans were reviewed and updated every quarter according to the resident's date their Minimum Data Set (MDS) was completed. Interview on 05/06/14 at 2:40 PM with the MDS Coordinator/RN revealed she conducted the review and update of the care plans. She stated usually this was an ongoing process, "I am out here with the residents and staff talking to the residents and we all talk about what is appropriate for whom and I update the care plans every third month, they reflect the MDS, and the CNA's care plan reflects the Nurse's Care Plan. We all give input and if we see any inconsistencies with the resident's ability we notify Sister, the ADON. Interview on 05/12/14 at 2:40 PM with LPN #2 revealed she was familiar with the review and update of the care plans. She stated the MDS Coordinator usually updates them every month. LPN #2 stated the MDS Coordinator was out on the Unit talking to the residents and staff. Interview on 05/12/14 at 4:55 PM with RN #1 revealed she recalled all staff was verbally reminded of the importance of following each resident's care plan. An example was voiced of walking with the resident if that is what the care plan indicated, if we don't see that it is followed we are not doing the right nursing care. As an RN, "I must see that the care plans are followed for the resident's well being." Interview on 05/22/14 at 5:29 PM with RN #2 revealed she has worked in the facility for one (1) month and was familiar with the review and update of the care plans. She stated the MDS Coordinator usually does that every so often. She further stated the MDS Coordinator was out on the Unit talking to the residents and staff. We all give input and if we see any inconsistencies we notify "Sister, the ADON". Review on 04/30/14 at 4:00 PM revealed in-service logs entitled "Resident safe Environment" and staff roster with signatures indicating attendance, dated 04/11/14. This inservice covered wheelchair safety, stress, burn-out, coping, gait belt use, oral care, cell phone use; and, abuse inservice signatures which indicated ninety- four (94) staff members attended the in-service between 04/11/14 and 04/14/14. Review on 05/12/14 of the in-service logs, dated 05/05/14, revealed all staff was inserviced related to abuse, neglect, recognizing and reporting signs of stress and burn-out, and following the plan of care. On 05/12/14 at 2:10 PM, CNA #9 verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. Interview on 05/12/14 at 2:17 PM with CNA #10; and at 2:40 PM with LPN #4, revealed they had received the in-service education on 05/02/14 by the ADON and they were aware of the signs/symptoms of abuse. The training also included to report to a supervisor immediately any allegation or witnessed abusive situations and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. On 05/12/14 at 2:45 PM, a housekeeper verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. On 05/12/14 at 4:55 PM, RN #1; on 05/22/14 at 5:29 PM with RN #2, and at 5:50 PM with CMT #2 verified through interview that they had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings. The inservice also included caregiver stress and signs of burn-out, and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. Interview on 05/22/14 at 5:55 PM with CNA #11 revealed she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the Nuns even to the point of interrupting prayer. She stated, "I would get a Sister because I feel like we should treat these people like they are our grandparents and you want your grandparents treated well." On 05/22/14 at 5:45 PM, CNA #12 verified through interview that she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the nuns even to the point of interrupting prayer."If it's wrong it's wrong, you can't let somebody get away with treating somebody mean you got to tell someone." Record review on 05/22/14 at 6:00 PM revealed the abuse allegations, the investigations, and the action plan was reviewed. Further review of a form entitled Continuous Quality Improvement; the Indicator: Knowledge and Compliance of Abuse and Reporting Policy; Recognizing Stress and Burn-out revealed one-hundred-seven (107) (all the facility staff) staff members received the re-education and in-service training and signed the rosters, their time-cards were held until their signatures were obtained in statement of participation. Through explanation by the ADON, random employees were asked Criteria/Question such as: stating the chain of command, know when to report, Identifies signs/symptoms of self stress and self burnout, names of coping strategies, know where to find contact numbers for reporting abuse. Each department will conduct these compliance rounds weekly and calculate the percentage of compliance. This will be conducted under the supervision of the DON and results will be reported to the QA committee. If an acceptable threshold of compliance is not achieved the DON will develop and oversee a corrective action. Compliance rounds are conducted weekly by the Administrative nursing staff to determine that resident care interventions are being provided in accordance with the care plan. Interview on 05/22/14 at 6:15 PM with the Medical Director revealed he was informed of the timing for the QA Committee meetings and he had attended the primary discussion with the Administrator, DON and ADON on 05/06/14. Further interview revealed he felt the facility was taking responsibility and being proactive with the QA plan they have put in place.

Based on interview, record review and review of a video recording and the facility's policy and procedure it was determined the facility failed to ensure staff implemented the facility's "Resident Safe Environment" policy and procedure for two (2) of nine (9) sampled residents (Resident #1 and Resident #4). Review of a cellular telephone video recording revealed on 04/07/14 at approximately 3:00 AM, Licensed Practical Nurse (LPN) #1 had Resident #1 sitting at the Nurse's Station with three (3) over the bed tables placed around the resident to prevent him/her from wandering. LPN #1 was calling Resident #1 "a brat", pointing and shaking her finger at the resident and talking to the resident in a commanding voice. Resident #1 was audibly crying. Further review revealed three (3) other staff, Certified Nurse Aides (CNA) #1, CNA #2 and CNA #3 witnessed the incident. However, the CNAs failed to report the mistreatment to Administration immediately per the facility's policy and procedure. Additionally, on 05/01/14 at 7:30 PM, CNA #5 observed Certified Medication Technician (CMT#1) grab Resident #4's hands tightly and hold the resident's hands in his/her lap. CMT #1 and LPN #3 then wheeled the resident backwards down the hallway to the resident's room in a wheelchair. Once in the room, CMT #1 removed Resident #4's sweater roughly and then pulled the wheelchair from under Resident #4 causing him/her to be suspended above the fall mat in his/her room. CMT #1 then roughly lifted Resident #4 from the wheelchair and "flung" him/her on the side of the bed. LPN #3 and CNA #5 both observed CMT #5's mistreatment of [REDACTED]. However, they failed to report the mistreatment to Administration immediately per the facility's policy and procedure. The facility's failure to ensure staff reported observed incidents of abuse to the Administration immediately has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 05/01/14 and determined to exist on 04/07/14. The facility was notified of the Immediate Jeopardy on 05/01/14. The findings include: Review of the facility's "Resident Safe Environment" policy and procedures, (not dated), revealed each resident has the right to be free from verbal, physical, sexual, and mental harassment or abuse. The policy included the following definitions: Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish; Verbal Abuse - any use of oral, gestured, language that includes disparaging and derogatory terms to residents regardless of their ability to comprehend; Physical Abuse - as controlling behavior through corporal punishment; and Mental Abuse: as harassment, threats of punishment or deprivation. Any alleged incidents of abuse, neglect, or exploitation must be reported immediately to the appropriate supervisor; the Administrator of the facility must be immediately notified. 1. Record review revealed the facility admitted Resident #1 on 05/09/13 with [DIAGNOSES REDACTED]. Review of the cell phone video recording, on 04/29/14 at 9:37 AM, revealed on 04/07/14 at approximately 3:00 AM, LPN #1 and Resident #1 were sitting in the Nurse's Station and there were over the bed tables placed around the resident to prevent him/her from wandering. LPN #1 was telling Resident #1 to "sit down" repeatedly in a commanding voice and she was calling Resident #1 "a brat". Resident #1 could be heard crying. Further review revealed two (2) other staff members (CNA #1 and CNA #2), who were partially visible; and the voice of a third staff member identified by the Director of Nursing as CNA #3. The three (3) CNAs observed LPN #1 blocking Resident #1 in the Nurse's Station and heard the verbal remarks made to Resident #1 by LPN #1. However, no one reported the incident to the Administrator, as per policy. Interview with CNA #1, CNA #2 and CNA #3, on 04/29/14 at 2:45 PM and 3:10 PM; and, on 04/30/14 at 9:05 AM respectively, revealed the CNAs were intimidated by the LPN and she treated them like she was a "Drill Sergeant". The CNAs stated they did not report any of the incidents because of fear of retaliation by the LPN. CNA #1 stated she waited and reported the incident on 04/08/14 when the LPN was not at work. 2. Record review revealed the facility admitted Resident #4 on 01/20/14 with [DIAGNOSES REDACTED]. Interview, on 05/06/14 at 3:47 PM with CNA #5, revealed on 05/01/14 around 7:30 PM, she witnessed CMT #1 grab Resident #1's hands tightly and cross the resident's hands across his/her lap as LPN #1 pulled his/her wheelchair backwards down the hallway taking Resident#1 into his/her room. CNA #5 stated CMT #1 roughly removed the resident's sweater and pulled the wheelchair from under Resident #1 causing the resident to be suspended above the fall mat in his/her room. In addition, CNA #5 stated CMT #1 roughly lifted Resident #1 from the wheelchair and "flung" him/her on the side of the bed. CNA #5 stated she did not report the incident to Administration immediately per the facility's policy and procedure, but she reported it at the end of the shift at 10:30 PM. The CNA stated she waited for LPN #3 to report the mistreatment but when the LPN had not reported it by the end of the shift, she called the DON. Interview, on 05/07/14 at 1:50 PM with LPN #3, revealed on 05/01/14 at 7:30 PM she had observed CMT #1 "pry the resident's hands off the wheels of the wheelchair, grasp them tightly and cross them across the resident's lap." The LPN stated she pulled Resident #4 backwards down the hallway and into his/her room. LPN #3 stated she then observed CMT #1 pull Resident #4's sweater off over his/her head roughly and lift the resident and put him/her on the bedside. The LPN stated the facility's policy was to report immediately but, "It was shift change before I realized it and I did not report the incident." Interview with the Administrator and DON, on 04/29/14 at 9:37 AM and on 05/06/14 at 2:45 PM, revealed all staff had been educated on the "Resident Safe Environment" policy and the staff who witnessed these incidents should have reported the mistreatment of [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 04/08/14, the facility suspended, then terminated LPN #1. The incident involving LPN #1 was then reported to the Kentucky Board of Nursing by the facility's DON. On 04/08/14 and 05/05/14, the Assistant Director of Nursing (ADON) conducted physical assessments on all the non-interviewable residents for signs/symptoms of possible abuse and interviews on all interviewable residents; no injuries were found. Further on 05/02/14, the ADON conducted interviews on all interviewable residents (those with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher to identify concerns related to care or any staff member, or events involving possible mistreatment by the staff or others with no concerns identified. The Nurse Care Plans for all residents were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 04/08/14 and repeated the interviews on 05/05/14 as education and re-education and training as part of their in-service training on the facility's abuse policy. Time cards were removed from the clock-in area and were not issued to the employees until the re-education was completed. Quality Assurance (QA) monitors began on 05/05/14 and included all facility staff and Continuous Quality Improvement (CQI) indicators for monitoring compliance with Care Planning to be conducted monthly for six (6) months beginning one month from 05/06/14 then quarterly thereafter under the supervision of the DON. Audits to be reported to the QA committee and a threshold of compliance is referenced as no abusive situations or reports. Compliance rounds are to be conducted weekly by the Administrator nursing staff to ensure compliance with resident care interventions being provided in accordance with the care plan. The State Agency validated the Corrective Action taken by the facility as follows: Interview on 05/22/14 at 4:00 PM with the Administrator revealed she was aware the Director of Nursing (DON) reported LPN #1's abusive behavior to the Kentucky Board of Nursing (KBN) on 05/02/14. Further interview on 05/22/14 at 4:00 PM with the Administrator revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14; LPN #3 is not eligible for rehire. CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility according to the Administrator. Additionally, interview on 05/22/14 at 4:00 PM with the Administrator revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administrator in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Interview on 05/22/14 at 4:30 PM with the Assistant Director of Nursing (ADON) revealed she was aware the DON reported LPN #1's abusive behavior to the KBN on 05/02/14. Further interview on 05/22/14 at 4:30 PM with the ADON revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14 and is not eligible for rehire; further CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility. Additionally, interview on 05/22/14 at 4:30 PM with the ADON revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administration in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Record review on 05/22/14 at 5:10 PM revealed an Employee Exit Interview dated 04/16/14 that shows LPN #1 was terminated on 04/16/14 and is not eligible for rehire. Further record review revealed LPN #3 and CMT #1 were suspended on 05/01/14 and 05/02/14 respectively, and then employment from the facility was terminated on 05/12/14 and neither are eligible for rehire at the facility. Additionally; CNA #1, CNA #2, CNA #3 received final written warnings and any future infraction will result in termination of employment at the facility, CNA #5 received counseling related to the reporting of abuse, neglect or mistreatment of [REDACTED]. Interview on 05/22/14 at 4:00 PM with the Administrator revealed she had oversight and that the ADON had conducted physical assessments and individually interviewed all residents of the Skilled Nursing Facility (SNF) on 04/08/14 and no findings of abuse were identified. Additionally she stated the ADON conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Interview on 05/22/14 at 4:30 PM with the ADON revealed she conducted physical assessments and individually interviewed all residents of the SNF on 04/08/14 and no findings of abuse were identified. Additionally she states she conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Record review on 05/12/14 at 3:00 PM revealed the physical assessments and the interviews with all residents of the SNF were conducted and recorded by the ADON and that no concerns were identified. Interview on 05/07/14 at 8:15 AM with the MDS Coordinator, who is a Registered Nurse (RN) revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the "Sisters". Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters, further stating the abuse hotline number was posted beside the time clock. Interview on 05/07/14 at 8:40 AM with a Housekeeper revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14. Her signature was noted on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go higher up or notify the DON or one of the Sisters. Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/22/14 at 5:29 PM with RN #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go to a higher up and notify the DON or one of the Sisters. She stated the primary concern was to keep the resident safe and remove the alleged perpetrator from the building immediately, "it's not just that we hear about abuse and have inservices on them, if you have a gut feeling something is wrong you do something about it." Interview on 05/07/14 at 5:45 PM with CNA #12 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" , or notify the DON or one of the Sisters. She further stated, "We have in-services and meetings frequently it seems, several times since I came seven (7) months ago, it's like fire and severe weather drills you should know what to do, wrong is wrong, report it immediately. Go to a nurse, if it's a nurse call the ADON or the DON and there's the numbers by the time clock for the Hotline if you need it." Interview on 05/22/14 at 5:50 PM with CMT #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON, or one of the Sisters. Interview on 05/22/14 at 6:00 PM with CNA #11 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety, abuse or mistreatment of [REDACTED]. She further stated they gave us all a sheet with their numbers on it so we can call them anytime we need to, as well. The Sisters have beepers if we need them. Interview on 05/07/14 at 6:05 PM with CNA #13 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/07/14 at 6:15 PM with a Dietary Staff Member revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/06/14 at 3:45 PM with the DON revealed she assigned the MDS Coordinator to review all residents' care plans on 04/11/14 and 05/05/14 for appropriateness, applicable problems, goals and interventions or approaches. The Nurse's Care Plans were reviewed and updated every quarter according to the resident's date their Minimum Data Set (MDS) was completed. Interview on 05/06/14 at 2:40 PM with the MDS Coordinator/RN revealed she conducted the review and update of the care plans. She stated usually this was an ongoing process, "I am out here with the residents and staff talking to the residents and we all talk about what is appropriate for whom and I update the care plans every third month, they reflect the MDS, and the CNA's care plan reflects the Nurse's Care Plan. We all give input and if we see any inconsistencies with the resident's ability we notify Sister, the ADON. Interview on 05/12/14 at 2:40 PM with LPN #2 revealed she was familiar with the review and update of the care plans. She stated the MDS Coordinator usually updates them every month. LPN #2 stated the MDS Coordinator was out on the Unit talking to the residents and staff. Interview on 05/12/14 at 4:55 PM with RN #1 revealed she recalled all staff was verbally reminded of the importance of following each resident's care plan. An example was voiced of walking with the resident if that is what the care plan indicated, if we don't see that it is followed we are not doing the right nursing care. As an RN, "I must see that the care plans are followed for the resident's well being." Interview on 05/22/14 at 5:29 PM with RN #2 revealed she has worked in the facility for one (1) month and was familiar with the review and update of the care plans. She stated the MDS Coordinator usually does that every so often. She further stated the MDS Coordinator was out on the Unit talking to the residents and staff. We all give input and if we see any inconsistencies we notify "Sister, the ADON". Review on 04/30/14 at 4:00 PM revealed in-service logs entitled "Resident safe Environment" and staff roster with signatures indicating attendance, dated 04/11/14. This inservice covered wheelchair safety, stress, burn-out, coping, gait belt use, oral care, cell phone use; and, abuse inservice signatures which indicated ninety- four (94) staff members attended the in-service between 04/11/14 and 04/14/14. Review on 05/12/14 of the in-service logs, dated 05/05/14, revealed all staff was inserviced related to abuse, neglect, recognizing and reporting signs of stress and burn-out, and following the plan of care. On 05/12/14 at 2:10 PM, CNA #9 verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. Interview on 05/12/14 at 2:17 PM with CNA #10; and at 2:40 PM with LPN #4, revealed they had received the in-service education on 05/02/14 by the ADON and they were aware of the signs/symptoms of abuse. The training also included to report to a supervisor immediately any allegation or witnessed abusive situations and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. On 05/12/14 at 2:45 PM, a housekeeper verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. On 05/12/14 at 4:55 PM, RN #1; on 05/22/14 at 5:29 PM with RN #2, and at 5:50 PM with CMT #2 verified through interview that they had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings. The inservice also included caregiver stress and signs of burn-out, and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. Interview on 05/22/14 at 5:55 PM with CNA #11 revealed she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the Nuns even to the point of interrupting prayer. She stated, "I would get a Sister because I feel like we should treat these people like they are our grandparents and you want your grandparents treated well." On 05/22/14 at 5:45 PM, CNA #12 verified through interview that she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the nuns even to the point of interrupting prayer."If it's wrong it's wrong, you can't let somebody get away with treating somebody mean you got to tell someone." Record review on 05/22/14 at 6:00 PM revealed the abuse allegations, the investigations, and the action plan was reviewed. Further review of a form entitled Continuous Quality Improvement; the Indicator: Knowledge and Compliance of Abuse and Reporting Policy; Recognizing Stress and Burn-out revealed one-hundred-seven (107) (all the facility staff) staff members received the re-education and in-service training and signed the rosters, their time-cards were held until their signatures were obtained in statement of participation. Through explanation by the ADON, random employees were asked Criteria/Question such as: stating the chain of command, know when to report, Identifies signs/symptoms of self stress and self burnout, names of coping strategies, know where to find contact numbers for reporting abuse. Each department will conduct these compliance rounds weekly and calculate the percentage of compliance. This will be conducted under the supervision of the DON and results will be reported to the QA committee. If an acceptable threshold of compliance is not achieved the DON will develop and oversee a corrective action. Compliance rounds are conducted weekly by the Administrative nursing staff to determine that resident care interventions are being provided in accordance with the care plan. Interview on 05/22/14 at 6:15 PM with the Medical Director revealed he was informed of the timing for the QA Committee meetings and he had attended the primary discussion with the Administrator, DON and ADON on 05/06/14. Further interview revealed he felt the facility was taking responsibility and being proactive with the QA plan they have put in place.

Based on interview, record review, and review of a cellular telephone video recording and the facility's policy and procedure it was determined the facility failed to follow the written plan of care for one (1) of nine (9) sampled residents (Resident #1). Resident #1 was assessed and care planned for the behavior of wandering. An intervention was in place to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and snack. Review of a video recording revealed on 04/07/14 at approximately 3:00 AM, Licensed Practical Nurse (LPN) #1 was with Resident #1 in the Nurse's Station with three (3) over the bed tables around the resident to prevent him/her from wandering. LPN #1 was calling Resident #1 "a Brat", and speaking to the resident in a commanding tone and Resident #1 was crying. Further review of the video revealed no evidence the resident was offered any diversions, activities, food, conversation, television and/or a book. The facility's failure to ensure staff followed the resident's written plan of care has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 05/01/14 and determined to exist on 04/07/14. The facility was notified of the Immediate Jeopardy on 05/01/14. The findings include: Record review revealed the facility admitted Resident #1 on 05/09/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment, dated 12/14/13, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of a three (3), which indicated the resident was not interviewable. Resident #1 exhibited the behavior of wandering. Review of the Comprehensive Care Plan for Elopement Risk/Wandering, dated 06/28/13, revealed interventions to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book. Review of a video recording, dated 04/07/14 at approximately 3:00 AM, revealed Licensed Practical Nurse (LPN) #1 with Resident #1 in the Nurse's Station with three (3) over the bed tables around the resident to prevent him/her from wandering. LPN #1 could be heard calling Resident #1 "a Brat", and speaking to the resident in a commanding tone. Resident #1 was crying. Further review of the video revealed no evidence staff offered the resident any diversions, activities, food, conversation, television and/or a book, as per the care plan. Interview, on 05/02/14 at 3:38 PM with LPN #1, revealed the resident was care planned to offer diversions. However, she stated, "I thought I was keeping (him/her) safe by making him/her sit down". Interview, on 05/22/14 at 4:55 PM with the ADON, revealed she or the Minimum Data Set (MDS) Coordinator reviewed and updated the Residents' Care Plans monthly, and as needed to ensure up to date Care Planning was completed. Further interview revealed she was on the nursing unit on a daily basis and could verify the Care Plans were followed. Additionally, she stated the CNA Care Plans were updated daily and a paper copy of the daily log was distributed to the staff on duty. Interview, on 04/29/14 at 9:30 AM with the Director of Nursing, revealed she expected staff to follow the residents' care plans. She further stated Resident #1 should have been allowed to walk in the hallways of the Infirmary. **The facility implemented the following actions to remove the Immediate Jeopardy: On 04/08/14, the facility suspended, then terminated LPN #1. The incident involving LPN #1 was then reported to the Kentucky Board of Nursing by the facility's DON. On 04/08/14 and 05/05/14, the Assistant Director of Nursing (ADON) conducted physical assessments on all the non-interviewable residents for signs/symptoms of possible abuse and interviews on all interviewable residents; no injuries were found. Further on 05/02/14, the ADON conducted interviews on all interviewable residents (those with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher to identify concerns related to care or any staff member, or events involving possible mistreatment by the staff or others with no concerns identified. The Nurse Care Plans for all residents were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 04/08/14 and repeated the interviews on 05/05/14 as education and re-education and training as part of their in-service training on the facility's abuse policy. Time cards were removed from the clock-in area and were not issued to the employees until the re-education was completed. Quality Assurance (QA) monitors began on 05/05/14 and included all facility staff and Continuous Quality Improvement (CQI) indicators for monitoring compliance with Care Planning to be conducted monthly for six (6) months beginning one month from 05/06/14 then quarterly thereafter under the supervision of the DON. Audits to be reported to the QA committee and a threshold of compliance is referenced as no abusive situations or reports. Compliance rounds are to be conducted weekly by the Administrator nursing staff to ensure compliance with resident care interventions being provided in accordance with the care plan. The State Agency validated the Corrective Action taken by the facility as follows: Interview on 05/22/14 at 4:00 PM with the Administrator revealed she was aware the Director of Nursing (DON) reported LPN #1's abusive behavior to the Kentucky Board of Nursing (KBN) on 05/02/14. Further interview on 05/22/14 at 4:00 PM with the Administrator revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14; LPN #3 is not eligible for rehire. CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility according to the Administrator. Additionally, interview on 05/22/14 at 4:00 PM with the Administrator revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administrator in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Interview on 05/22/14 at 4:30 PM with the Assistant Director of Nursing (ADON) revealed she was aware the DON reported LPN #1's abusive behavior to the KBN on 05/02/14. Further interview on 05/22/14 at 4:30 PM with the ADON revealed LPN #3 was suspended on 05/01/14 and employment terminated on 05/05/14 as evidenced by an Employee Exit Interview completed by the DON on 05/05/14 and is not eligible for rehire; further CMT #1 was suspended on 05/02/14 and employment terminated on 05/12/14 and she is not eligible for rehire at the facility. Additionally, interview on 05/22/14 at 4:30 PM with the ADON revealed that CNA #1, CNA #2 and CNA #3 received a final written warning on 04/11/14 for failure to report the abusive behavior of LPN #1 to the Administration in a timely manner; further interview revealed that future infractions will result in termination of employment from the facility. Record review on 05/22/14 at 5:10 PM revealed an Employee Exit Interview dated 04/16/14 that shows LPN #1 was terminated on 04/16/14 and is not eligible for rehire. Further record review revealed LPN #3 and CMT #1 were suspended on 05/01/14 and 05/02/14 respectively, and then employment from the facility was terminated on 05/12/14 and neither are eligible for rehire at the facility. Additionally; CNA #1, CNA #2, CNA #3 received final written warnings and any future infraction will result in termination of employment at the facility, CNA #5 received counseling related to the reporting of abuse, neglect or mistreatment of [REDACTED]. Interview on 05/22/14 at 4:00 PM with the Administrator revealed she had oversight and that the ADON had conducted physical assessments and individually interviewed all residents of the Skilled Nursing Facility (SNF) on 04/08/14 and no findings of abuse were identified. Additionally she stated the ADON conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Interview on 05/22/14 at 4:30 PM with the ADON revealed she conducted physical assessments and individually interviewed all residents of the SNF on 04/08/14 and no findings of abuse were identified. Additionally she states she conducted mood and behavior assessments on all the residents of the SNF and no concerns were identified. Record review on 05/12/14 at 3:00 PM revealed the physical assessments and the interviews with all residents of the SNF were conducted and recorded by the ADON and that no concerns were identified. Interview on 05/07/14 at 8:15 AM with the MDS Coordinator, who is a Registered Nurse (RN) revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the "Sisters". Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters, further stating the abuse hotline number was posted beside the time clock. Interview on 05/07/14 at 8:40 AM with a Housekeeper revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14. Her signature was noted on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go higher up or notify the DON or one of the Sisters. Interview on 05/07/14 at 8:20 AM with CNA #6 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/22/14 at 5:29 PM with RN #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to the DON, ADON or Administrator immediately, if the incident involved a superior she would go to a higher up and notify the DON or one of the Sisters. She stated the primary concern was to keep the resident safe and remove the alleged perpetrator from the building immediately, "it's not just that we hear about abuse and have inservices on them, if you have a gut feeling something is wrong you do something about it." Interview on 05/07/14 at 5:45 PM with CNA #12 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" , or notify the DON or one of the Sisters. She further stated, "We have in-services and meetings frequently it seems, several times since I came seven (7) months ago, it's like fire and severe weather drills you should know what to do, wrong is wrong, report it immediately. Go to a nurse, if it's a nurse call the ADON or the DON and there's the numbers by the time clock for the Hotline if you need it." Interview on 05/22/14 at 5:50 PM with CMT #2 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON, or one of the Sisters. Interview on 05/22/14 at 6:00 PM with CNA #11 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety, abuse or mistreatment of [REDACTED]. She further stated they gave us all a sheet with their numbers on it so we can call them anytime we need to, as well. The Sisters have beepers if we need them. Interview on 05/07/14 at 6:05 PM with CNA #13 revealed she received in-service training on abuse/neglect and reporting to Administration on 05/02/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/07/14 at 6:15 PM with a Dietary Staff Member revealed she received in-service training on abuse/neglect and reporting to Administration on 05/05/14 as evidenced by her signature on the in-service training roster. Further interview revealed she would report any concerns for resident safety to a Charge Nurse, the DON, ADON or Administrator immediately, if the incident involved a superior she would go "up the chain of command" and notify the DON or one of the Sisters. Interview on 05/06/14 at 3:45 PM with the DON revealed she assigned the MDS Coordinator to review all residents' care plans on 04/11/14 and 05/05/14 for appropriateness, applicable problems, goals and interventions or approaches. The Nurse's Care Plans were reviewed and updated every quarter according to the resident's date their Minimum Data Set (MDS) was completed. Interview on 05/06/14 at 2:40 PM with the MDS Coordinator/RN revealed she conducted the review and update of the care plans. She stated usually this was an ongoing process, "I am out here with the residents and staff talking to the residents and we all talk about what is appropriate for whom and I update the care plans every third month, they reflect the MDS, and the CNA's care plan reflects the Nurse's Care Plan. We all give input and if we see any inconsistencies with the resident's ability we notify Sister, the ADON. Interview on 05/12/14 at 2:40 PM with LPN #2 revealed she was familiar with the review and update of the care plans. She stated the MDS Coordinator usually updates them every month. LPN #2 stated the MDS Coordinator was out on the Unit talking to the residents and staff. Interview on 05/12/14 at 4:55 PM with RN #1 revealed she recalled all staff was verbally reminded of the importance of following each resident's care plan. An example was voiced of walking with the resident if that is what the care plan indicated, if we don't see that it is followed we are not doing the right nursing care. As an RN, "I must see that the care plans are followed for the resident's well being." Interview on 05/22/14 at 5:29 PM with RN #2 revealed she has worked in the facility for one (1) month and was familiar with the review and update of the care plans. She stated the MDS Coordinator usually does that every so often. She further stated the MDS Coordinator was out on the Unit talking to the residents and staff. We all give input and if we see any inconsistencies we notify "Sister, the ADON". Review on 04/30/14 at 4:00 PM revealed in-service logs entitled "Resident safe Environment" and staff roster with signatures indicating attendance, dated 04/11/14. This inservice covered wheelchair safety, stress, burn-out, coping, gait belt use, oral care, cell phone use; and, abuse inservice signatures which indicated ninety- four (94) staff members attended the in-service between 04/11/14 and 04/14/14. Review on 05/12/14 of the in-service logs, dated 05/05/14, revealed all staff was inserviced related to abuse, neglect, recognizing and reporting signs of stress and burn-out, and following the plan of care. On 05/12/14 at 2:10 PM, CNA #9 verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. Interview on 05/12/14 at 2:17 PM with CNA #10; and at 2:40 PM with LPN #4, revealed they had received the in-service education on 05/02/14 by the ADON and they were aware of the signs/symptoms of abuse. The training also included to report to a supervisor immediately any allegation or witnessed abusive situations and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. On 05/12/14 at 2:45 PM, a housekeeper verified through interview that she had received the inservice education on 05/03/14 by the ADON and she knew to report anything she felt as abusive in nature to a supervisor immediately. On 05/12/14 at 4:55 PM, RN #1; on 05/22/14 at 5:29 PM with RN #2, and at 5:50 PM with CMT #2 verified through interview that they had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings. The inservice also included caregiver stress and signs of burn-out, and if supervisory staff was involved to call on one of the Nuns even to the point of interrupting prayer. Interview on 05/22/14 at 5:55 PM with CNA #11 revealed she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the Nuns even to the point of interrupting prayer. She stated, "I would get a Sister because I feel like we should treat these people like they are our grandparents and you want your grandparents treated well." On 05/22/14 at 5:45 PM, CNA #12 verified through interview that she had received the inservice training by the ADON. The inservice training included forms of abuse; verbal, physical, mental, and misappropriation of resident belongings, the inservice also included caregiver stress and signs of burn-out, and if supervisory staff is involved to call on one of the nuns even to the point of interrupting prayer."If it's wrong it's wrong, you can't let somebody get away with treating somebody mean you got to tell someone." Record review on 05/22/14 at 6:00 PM revealed the abuse allegations, the investigations, and the action plan was reviewed. Further review of a form entitled Continuous Quality Improvement; the Indicator: Knowledge and Compliance of Abuse and Reporting Policy; Recognizing Stress and Burn-out revealed one-hundred-seven (107) (all the facility staff) staff members received the re-education and in-service training and signed the rosters, their time-cards were held until their signatures were obtained in statement of participation. Through explanation by the ADON, random employees were asked Criteria/Question such as: stating the chain of command, know when to report, Identifies signs/symptoms of self stress and self burnout, names of coping strategies, know where to find contact numbers for reporting abuse. Each department will conduct these compliance rounds weekly and calculate the percentage of compliance. This will be conducted under the supervision of the DON and results will be reported to the QA committee. If an acceptable threshold of compliance is not achieved the DON will develop and oversee a corrective action. Compliance rounds are conducted weekly by the Administrative nursing staff to determine that resident care interventions are being provided in accordance with the care plan. Interview on 05/22/14 at 6:15 PM with the Medical Director revealed he was informed of the timing for the QA Committee meetings and he had attended the primary discussion with the Administrator, DON and ADON on 05/06/14. Further interview revealed he felt the facility was taking responsibility and being proactive with the QA plan they have put in place.