Every finding on record at Clearview Brain Injury Center

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 11 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for five fiscal year quarters for failure to have licensed nursing coverage 24 hours a day. Evidenced by: (It is important to understand the foundation of this facility to grasp where these errors are occurring. This facility campus houses residents in 7 different licensed entities. There is one Brain Injury Center, one Skilled Nursing Facility, one unit for Individuals with Intellectual Disabilities, and four Behavioral Health units. Although these entities are separate licenses, they share one big campus and share some of the staff members like the Director of Nursing, the Facility Administrator, and RN Supervisors (Registered Nurse). Facility policy, entitled How to do the PBJ Report for CMS, undated, includes: You will need to get the RN (Registered Nurse) staffing assignments by zone . these will help you pro-rating the licensed staff and determine where they worked . The following administrative staff get pro-rated:1) Pro-rated based on # of beds: 51% other facility licenses, 13% to this facility's license: Director of Nursing Services, Executive Director, Assistant Director of Nursing, Director of Dietary Services, Registered Nurse Practitioner, In-Service Coordinator. 2) Pro-rated based on workload: 75% other facility licenses, 3% to this facility's license: Director of Life Enrichment Services. 3) Pro-rated based on workload: 50% other facility licenses, 50% to this facility license: Director of Social Services Coordinator. 4) Pro-rated based on workload: . Admissions Clinical Coordinator. 5) Pro-rated based on workload: 75% other facility licenses, 18.4% this facility license: Minimum Data Set Coordinator . The following are how the Team Leaders and RN Supervisors get pro-rated: Team Lead AM: 100% this facility license, Team Lead PM: 100% this facility license, Team Lead Night Shift (NOC): 60% this facility license . RN Supervisor Weekend: AM-20% this facility license, PM-20% this facility license, NOC- 20% this facility license . RN Supervisor Weeks: AM- 100% this facility's license, PM-20% this facility license, NOC- 20% this facility license . Determining/Pro-rating Hours: RNs who work the PM shift are pro-rated so that 20% of their time goes to this facility license, 80% goes to other facility licenses, This applies to the AM shift on the weekends . Team Leaders who work the NOC shift are pro-rated so that 60% of their time goes to this license and 40% of their time goes to another license. Certified Nursing Assistants who work on a different household are 100% allocated to that household. Example 1: CMS's PBJ Staffing Data Report, for fiscal year quarter 3 2023 (April 1-June 30), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates: 4/2, 4/7, 4/8, 4/9, 4/16, 4/23, 4/29, 4/30, 5/13, 5/14, 5/20, 5/21, 5/26, 5/28, 5/29, 5/30, 6/2, 6/3, 6/4, 6/10, 6/11, 6/18, 6/24, 6/25, 6/30 CMS [NAME] Report Staffing Summary Report, from 4/1/23 thru 6/30/23, includes, in part: 4/2 licensed nursing hours reported: 23.25. 4/7 licensed nursing hours reported: 22.95. 4/8 licensed nursing hours reported: 13.55. 4/9 licensed nursing hours reported: 15.70. 4/16 licensed nursing hours reported: 16.3. Example 2: CMS's PBJ Staffing Data Report, for fiscal year quarter 4 2023 (July 1-September 30), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates: 7/1, 7/2, 7/3, 7/5, 7/6, 7/8, 7/9, 7/15, 7/16, 7/22, 7/23, 7/24, 7/29, 7/30, 8/1, 8/4, 8/7, 8/12, 8/13, 8/17, 8/18, 8/19, 8/22, 8/26, 8/27, 8/29, 9/9, 9/10, 9/23, 9/24 CMS [NAME] Report Staffing Summary Report, from 7/1/23 thru 9/30/23, includes, in part: 7/1 licensed nursing hours reported: 15.72. 7/2 licensed nursing hours reported: 17.90. 7/3 licensed nursing hours reported: 18.30. 7/5 licensed nursing hours reported: 22.68. 7/6 licensed nursing hours reported:20.81. Example 3: CMS's PBJ Staffing Data Report, for fiscal year quarter 1 2024 (October 1-December 31), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates:10/1, 10/4, 10/6, 10/7, 10/8, 10/21, 10/22, 10/27, 11/4, 11/12, 12/25, 12/29 CMS [NAME] Report Staffing Summary Report, from 10/1/23 thru 12/31/23, includes, in part: 10/1 licensed nursing hours reported: 16.65. 12/25 licensed nursing hours reported: 17.47. 12/29 licensed nursing hours reported: 15.10. On 5/8/24 at 10:19 AM, BOM C (Business Office Manager) indicated she is responsible for completing the PBJ reporting, and she uses an equation to divide the licensed nursing hours amongst the different licensed entities in the home. BOM C indicated there is a licensed staff working 24 hours a day in this licensed entity. BOM C indicated on paper their hours are split between other licensed entities within the home. Surveyor asked if this is a true representation of the schedules if the staff are working for 8 hours, but only count as a percentage of that on the PBJ. BOM C indicated this is how she has been taught and has always done it this way. On 5/8/24 at 1:19 PM, DON B (Director of Nursing) indicated at no time is this unit left without a licensed nursing staff. There is a licensed nursing staff scheduled on all three shifts for only this unit and sometimes two licensed staff are scheduled. DON B indicated time for RN Supervisors is split between licenses. Surveyor asked if the reported data reflects this. DON B indicated it does not. On 5/8/24 at 2:08 PM, Payroll Coordinator D indicated there is never a time where there is no licensed nurse on the unit. Payroll Coordinator D indicated the data reported does not reflect that there is 24-hour licensed nurse coverage. On 5/8/24 at 3:26 PM, Rehabilitation Specialist E indicated there is never a time that the unit does not have a licensed nurse on it. On 5/8/24 at 3:27 PM, Social Worker F indicated there is always a licensed nurse on the unit. At no times is the unit without nurse coverage. It should be noted, a review of the licensed nursing schedule reflects a licensed nurse on the unit every shift.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R1) of 3 residents was free from sexual abuse. On 7/20/2021, the Surveyor reviewed a facility self-report. The self-report indicated R1 was found in R1's room with one of R1's CGs (Co-Guardians) in an intimate sexual interaction. R1's CG was R1's significant other and was visiting R1 from out of state. R1's care plan did not reflect if R1 was able to consent to having a sexual encounter with R1's significant other/CG and did not include guidance for staff related to R1's capacity to consent to sexual relations. Additionally, this allegation was not thoroughly investigated by the facility to determine if their had been previous incidents while CG-Cwas in the facility. Findings include: The facility's policy entitled Allegations of Misconduct with an effective date of 12/18/2020, indicated the facility will ensure residents are free from any form of abuse and that any alleged violations of misconduct are thoroughly investigated in a timely manner. Interviews will be conducted with all staff who may have knowledge of the incident. Interview staff from previous shifts to determine if they were aware of the incident or if the incident occurred on a prior shift. On 7/20/2021, the Surveyor reviewed R1's medical record. R1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission MDS (Minimum Data Set), dated 4/25/2021, indicated R1 had short-term and long-term memory problems, R1's cognition was severely impaired, R1 did not ambulate, required extensive assistance from staff for bed mobility, and was dependent on staff for transfers. R1's current electronic resident face sheet indicated R1 was not responsible for self and CG (co-guardian)-C was R1's significant other. CG-C resided out of state. Per the facility self-report, CG-C came to Wisconsin to visit R1 daily from 7/3/2021 - 7/12/2021. During the 7/12/2021 visit, at approximately 1:00 PM to 1:15 PM, CNA (Certified Nursing Assistant)-E knocked on R1's closed door. CNA-E did not hear anyone answer the knock. CNA-E walked into R1's room and observed CG-C under R1's blanket leaning over R1's waist line. CG-C stopped movement below the blanket, apologized and laughed. CNA-E apologized for coming in without hearing an answer and left R1's room to chart. While charting, CNA-E reflected on what happened in R1's room. CNA-E did not report what was witnessed immediately because CG-C, is (R1's) girlfriend and guardian. (R1) talks to (CG-C) every night. I was confused about what to do. But, I knew that (R1) has confusion and doesn't always remember who (CG-C) is. Because (R1) doesn't always know what is going on, and (R1) is in a place (R1) is safe, I knew I should report it. I don't know the rules about what resident's rights are about what they do with girlfriends, but I would think (R1) should be evaluated before (R1) could make that decision. At approximately 1:35 PM CNA-E reported the incident to the facility. CG-C left the facility after the incident. On 7/12/2021 at 3:20 PM, DSS (Director of Social Services)-D interviewed CG-C regarding the incident. CG-C stated R1 asked CG-C to pleasure R1. DSS-D asked what that meant, CG-C identified it as a blow job and confirmed CG-C and R1 had engaged in oral sex this afternoon. CG-C asked if it was a big deal that CG-C and R1 engaged in oral sex. DSS-D explained that based on R1's injury, R1's ability to consent was in question. CG-C verified CG-C and R1 had been engaging in kissing and laying next to each other during CG-C's other visits to the facility. DSS-D explained a sexual assessment would be beneficial to evaluate R1's cognitive understanding and ability to consent to romantic and sexual activities. Per the facility self-report, on 7/12/2021 at 2:42 PM, R1 was interviewed. R1 did not recall having any visitors on 7/12/2021. R1 identified CG-C as a friend, denied CG-C as a girlfriend, and denied feeling romantic or sexually involved with CG-G. R1 could not recall receiving oral sex from CG-C and stated,would not want that from CG-C. On 7/12/2021, a sexuality screen tool was completed on R1. R1 was not oriented to time, place or purpose. An assessment of R1's cognition indicated impairment was affecting R1's ability to consent. On 7/12/2021, R1's APNP (Advanced Practice Nurse Practitioner)-H completed an assessment on R1. The assessment indicated R1's severe cognitive impairment continued to incapacitate R1 from making informed decisions about care and would also preclude R1 from consenting to agreement of sexual activity. R1 continues to require and benefit from a proxy decision maker (court appointed guardian) for all aspects of care and safety at this time and will likely require such for the foreseeable future. On 7/13/2021, another sexuality screen tool was completed on R1. The screen indicated R1 appears to understand the general and basic concepts of sexuality, R1's confusion and cognitive impairment significantly impaired and limited his ability to give informed consent. R1's current psychosocial well-being alteration in thought/lifestyle related to [CONDITION(S)] plan of care, dated 4/30/2021, stated (R1) was dependent on staff for all cares at this time, has decreased cognitive and physical abilities, poor insight into deficits, poor orientation, confusion, and memory deficits. R1 was able to use head nods to indicate yes/no. R1 has been doing a lot more talking. R1 does have a significant other (CG-C) with whom R1 talks to everyday via Facetime (a mobile video calling service.) The significant other lives in another state. R1 usually Facetimes with (CG-C) two times per day. Approaches included CG-C and R1 to remain informed of staff and resident cases of COVID-19. A progress note will only added in the event of an adverse reaction to or specific concern about the notification. R1 Facetimes with his significant other (CG-C) at least twice daily for about one to two hours per time. At this point, R1 was only oriented to self. Sometimes thinks CG-C is a past girlfriend from another country. There was not an approach documented indicating if R1 was assessed if R1's significant other (CG-C) visited if R1 would be able to consent to a sexual encounter with CG-C and if staff were to enter the room when CG-C was visiting if there was not an answer after knocking on the door. Staff were not aware if R1 could be involved in a sexual encounter with CG-C or not because the care plan did not indicate an approach/intervention. On 7/20/2021 at 8:20 AM, the Surveyor interviewed DSS-D. DSS-D verified R1 did not have a care plan for sexual visits because the facility had no idea a sexual encounter would occur when CG-C visited from another state. DSS-D confirmed R1 and CG-C Facetime daily. On 7/20/2021 at 9:40 AM, the Surveyor interviewed DON (Director of Nursing)-B. DON-B verified R1 did not have a care plan for sexual visits because R1's significant other (CG-C) lived out of state. The facility did not expect a sexual encounter to occur when CG-C visited. CG-C has been in Wisconsin for two to three weeks. On 7/20/2021 at 11:57 AM, the Surveyor interviewed DSS-D about interviewing other staff regarding the allegation of sexual abuse. DSS-D stated other staff were not interviewed to determine if other staff had seen or heard any indications that there was sexual contact between R1 and CG-C during other visits prior to this allegation of sexual abuse. DSS-D confirmed other staff were not officially asked the question, but during staff education, the situation was reviewed, and no staff said anything further that would indicate sexual contact had been heard or seen by other staff prior to this allegation. On 7/20/2021 at 3:23 PM, the Surveyor interviewed DON-B. DON-B confirmed the facility did not have a care plan for anything sexual because it had been so long since R1 and CG-C had seen each other. The facility wasn't even sure if R1 and CG-C had a relationship anymore. R1 has a [CONDITION(S)], might be able to request oral sex one day, but not the next day. R1 states CG-C is R1's girlfriend one day, but not the next day. On 7/21/2021 at 10:00 AM, the Surveyor interviewed CNA-E regarding what happened on 7/12/2021 when CNA-E entered R1's room to find CG-C under the blankets at R1's waist area. CNA-E verified when CNA-E entered R1's room, CG-C was under the blankets at R1's waist area. CG-C quickly pulled out (CG-C's) head from under blankets and stated looks like we got caught. After the rumors spread about this incident, CNA-F and CNA-G indicated to CNA-E they had concerns about R1's underwear being ruffled during other times CG-C had visited, but were not sure if caused by CG-C, so had not reported it to the facility. CG-C had reported to CNA-E over the weekend prior to this occurring on Monday that R1 did not know who CG-C was. CNA-E stated if this person (R1) didn't know you, why is it okay to provide oral sex to that person? Normally, if residents are going to have a sexual encounter, they would go in a room we provide so we know not to interrupt. Without a care plan addressing a sexual encounter, it is a gray area. It should be in (R1's) care plan if (it is) okay or not to have a sexual encounter. Wasn't on the care plan or in R1's social history. CNA-E then stated CNA-E was advised the physician evaluates a resident's cognitive level to determine whether or not a resident was cognitively able to consent to a sexual encounter. R1 was not evaluated by a physician prior to the sexual encounter because R1 did not express the desire to have a sexual encounter. R1 was not assessed prior to R1's significant other/co-guardian coming to visit R1 to determine if R1 wanted to or could consent to a sexual encounter. R1's plan of care did not contain approaches/interventions to assist staff with knowing whether or not R1 could consent to having a sexual encounter with CG-C. Additionally, the investigation was not thoroughly investigated as the investigation did not include additional staff interviews regarding this allegation of sexual abuse to determine if any other staff had seen or heard any indications that there was sexual contact between R1 and CG-C during other visits prior to this allegation of sexual abuse.

The facility did not review and revise care plans to ensure each resident's Person-Centered Care Plan accurately reflected their care needs for 2 of 10 sampled residents (R11) and (R16). R11's care plan was not revised to indicate current goal is smoking cessation related to upcoming surgical procedure. R16's care plan did not include targeted behaviors for use of [MEDICAL CONDITION] medications. This is evidenced by: Example 1 R11 admitted to the facility in (MONTH) of (YEAR). R11 has the following Diagnoses: [REDACTED]. R11 had a smoking assessment and care plan developed upon admission indicating that R11 is safe to smoke with staff supervision. R11's After Visit Summary Sheet, from 1/8/19, with Neurosurgery Department documents refrain and quit smoking. Nurse's Note documents, in part: 01/28/2019 14:04 (2:04 PM) Call received from . Neurosurgery. States that Dr . reviewed labs and CSF (cerebrospinal fluid). States carbon monoxide and nicotine levels are too high and will not proceed with surgery until they are lower . On 2/13/19 at 3:32 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C to review After Visit Summary from neurosurgery, dated 1/8/19. Surveyor asked RN C if R11's care plan should have been updated with the new directive of refrain and quit smoking. RN C stated, up until the 20th, R11 was smoking on home passes, R11's daughter smokes in the vehicle, our main focus was to provide education to the family, but, as far as the care plan itself, R11 wasn't going out to smoke here. Care plan is saying R11 is safe to smoke. Surveyor asked RN C if the care plan is supposed to reflect how a person is to be cared for; RN C said yes and R11's should have changed to a Smoking Cessation Plan. On 2/13/19 at 4:00 PM, Surveyor interviewed RS D (Rehab Specialist). Surveyor asked RS D if R11's care plan should have been updated with new directive of refrain and quit smoking. RS D stated R11 still has the right to smoke, but we could have added to the care plan to encourage R11 not to and the reason why. On 2/13/19 at 5:02 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would have expected R11's care plan to be updated with the refrain and quit smoking, DON B said, yea. Example 2 R16 admitted to the facility in (MONTH) of (YEAR). R16 has the following Diagnoses: [REDACTED]. R16's Physician Orders, dated 2/19, document the following medications: [REDACTED]. Both of these medications are antidepressants by category and are [MEDICAL CONDITION] medications by classification. R16 does not have a care plan for sleep or [MEDICAL CONDITION] or use of [MEDICATION NAME] at bedtime. R16 does not have a care plan for person-centered target behaviors related to use of [MEDICAL CONDITION] medications. Psychiatric Services Note, dated 11/13/18, documents, in part: .R16 continues to exhibit confusion, poor insight, and delusions .R16 does become slightly agitated during the night .R16 has not been combative, threatening or hostile .There have been no objective signs of depression, i.e. no tearfulness or negative statements .Sleep appears to be relatively adequate .At this time, the only change I am going to make is to change [MEDICATION NAME] from HS (bedtime) to AM. It is possible this might result in some improvement in sleep pattern or level of agitation at bedtime. At this point, delusions/hallucinations/misperceptions of the environment do not seem to be sufficiently disturbing as to warrant treatment . On 2/13/19 at 1:58 PM, Surveyor interviewed DON B. DON B was asked to show Surveyor R16's behavior charting. DON B brought up in computer documented behaviors of short tempered and easily annoyed for this month. Surveyor asked DON B if these behaviors were the target behaviors for R16's [MEDICAL CONDITION] medications, DON B said yes. Surveyor asked DON B if these behaviors should be on the care plan, DON B said yes. On 2/13/19 at 2:31 PM, Surveyor interviewed CSW E (Certified Social Worker). Surveyor asked CSW E if R16 should have a care plan for use of [MEDICAL CONDITION] medication use and target behaviors, CSW E said yes. CSW E looked in computer and stated, I'm not seeing it, we all do these a little different and RS F covers R16, so I'll have RS F come talk with you. On 2/13/19 at 2:53 PM, Surveyor interviewed RS F. Surveyor asked RS F if R16 should have a care plan for sleep and use of [MEDICAL CONDITION] medications. RS F stated Nursing Care plans sleep, and getting up in the morning is the behavior; it's not usually an issue once up for the day. Surveyor asked RS F if R16 should have a care plan for antidepressant use, RS F said I think it's in APNP G (Advanced Practice Nurse Practitioner) note. On 2/13/19 at 3:27 PM, Surveyor interviewed RN C. Surveyor asked RN C if R16 should have a care plan for sleep. RN C said I think the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On 2/13/19 at 3:52 PM, Surveyor interviewed RN C. RN C explained R16 admitted with [DIAGNOSES REDACTED]. Surveyor asked RN C what person-centered target behaviors are the Certified Nursing Assistants (CNA's) documenting on for the use of [MEDICAL CONDITION] medications. RN C said the CNA's document hours of sleep daily to address the restlessness. Surveyor asked RN C what is the person-centered target behavior being documented for R16, RN C stated it should be in the behavior charting as agitation. Surveyor asked RN C what R16's agitation looks like. RN C would go pull up the documentation and bring it to Surveyor to review. On 2/13/19 at 4:24 PM, RN C returned with CNA documentation that the physician reviews to see if R16 is restless. This documentation shows the following behaviors: cursing at others, rummaging, wandering, hitting others, and threatening others. Surveyor asked RN C if these behaviors are on R16's care plan, RN C said, I don't know. On 2/13/19 at 4:55 PM, Surveyor interviewed DON B. Surveyor asked DON B if she would expect to see a care plan for [MEDICAL CONDITION] medication use. DON B stated, You would think it would be on the care plan.

Based on record review and interview, the facility did not ensure that Physician's Orders were signed and dated for 1 of 10 resident records reviewed (R4). R4's monthly Physician's Orders have not been signed or dated by the physician for (MONTH) or (MONTH) 2019. Evidenced by: R4 was a resident at the facility for over a year. R4's most recent signed Physician Orders were signed on 11/28/18 for 12/18 (December (YEAR)). On 2/12/19 at 2:08 PM, Surveyor asked HAI H (Household Information Assistant) if R4 had current signed Physician's Orders in medical record. HAI H said, (R4) should have new monthly order sheets in the medical paper chart for Jan and Feb. HAI H would look for them and get back to Surveyor. On 2/13/19 at 10:03 AM, HAI H stated that HAI H had called the pharmacy and they didn't have R4 as being admitted to the facility in (MONTH) (YEAR). HAI H stated that the facility does not have someone who ensures that monthly orders are in place for each resident and have never had a problem with this before. HAI H described the process of receiving the monthly Physician's Orders in a stack of papers from the pharmacy and HAI H or a nurse would sign for them, then they would be reviewed by at least 2 other staff (described, nurses, manager or supervisor) to ensure the orders are correct. On 2/13/19 at 12:54 PM, Surveyor interviewed the Unit RN C (Registered Nurse). Surveyor asked if there is a process to make sure all monthly orders are in place each month for each resident. RN C stated when the Physician's Orders come to the facility they are signed for by HAI H and reviewed by several people. RN C stated that with the previous computer system there was a way to check that each resident had their monthly Physician's Orders reviewed; with the new electronic medical record systems, RN C didn't know how each resident's Physician's Orders were in place each month. RN C stated the DON B (Director of Nursing) would be the person for the Surveyor to speak with about the process. On 2/13/19 at 1:05 PM, Surveyor interviewed DON B about the process of ensuring each resident has signed monthly Physician's Orders. DON B explained the Physician's Orders come from the pharmacy, the nurses (on the Unit) check them off when they come from pharmacy. Surveyor asked how the nurses check the Physician's Orders. DON B stated, They come and they are signed for. DON B continued that HAI H is supposed to check them and review the orders. HAI H and the RN Unit Managers and supervisors also review each sheet of orders and sign off on each sheet. DON B agreed that R4 should have signed Physician's Orders monthly in the medical chart.

Based on interview and record review, the facility does not have an established Infection Prevention and Control Program (IPCP) that includes a system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility for 4 of 4 units reviewed for infection control. The facility does not have a system in place for corrective actions related to UTI's (Urinary Tract Infection) that are positive for E. coli (Escherichia coli). Evidenced by: Surveyor reviewed Infection Control Data, provided by the facility, and noted multiple residents on each unit with UTI's and E. coli; many were recurrent. Surveyor did not see corrective action listed within the Infection Control Data. 11/9/17 at 9:10 AM, Surveyor interviewed ICP C (Infection Control Preventionist) about Infection Control Program. Surveyor asked ICP C if the facility had identified the UTI's that were positive for E. coli as a concern. ICP C stated they had. Surveyor asked ICP C if the facility had done corrective action in regards to these. ICP C stated they discuss in household meetings about proper handwashing and peri-care, verbal review, and question/answer checks with the staff. Surveyor asked ICP C to review any documentation showing corrective action. Household Meeting Minutes for area AB2, dated 7/28/17, documents .2hr peri-care UTI- E. coli- stool in urine track . while awake AM, PM, N(NAME) . (It is important to note that this documentation only represents 1 of the 4 units reviewed.) Five Perineal Care Audit Checklists were given to Surveyor. One audit is dated 9/25/17; the other audits do not indicate a date they were completed. Two of the five audits have resident rooms numbers present, the other audits do not indicate what unit the audits were completed on.

Based on interview and record review, the facility did not ensure that all allegations of alleged abuse violations are reported to the administrator, reported to the State Agency, and thoroughly investigated for 1 of 4 investigations reviewed. R5 (Resident) reported an alleged verbal abuse incident to the RN (Registered Nurse) Supervisor and the incident was documented in R5's medical record. The facility did not report the incident to the NHA (Nursing Home Administrator), State Survey Agency, or complete an investigation into the allegation to determine education needed or corrective action needed. Evidenced by: R5 was admitted to facility in September of 2016, following a TBI ([MEDICAL CONDITION]). His most recent MDS (Minimum Data Set), completed 6/26/17, documents that he scored a 15 on his BIMS (Brief Interview for Mental Status), which indicates that he is cognitively intact. Per Nurses Note on 7/19/17, FM D (Family Member) voiced a concern that a staff member walked up to R5 one day, pointed to a scar on her arm and stated, See this R5? You did this to me. FM D also stated that a day prior a staff member was visiting the household with her baby and R5 wanted to hold the baby. FM D stated that the staff member told R5, You can't hold him until you behave. Maybe someday when you know how to be good I will let you hold him. RN E (Registered Nurse Supervisor) documented in the Nurse's Note that she apologized to FM D and stated she had never witnessed any of this behavior from staff. FM D voiced that she felt the staff antagonized R5. (It is important to note that (Facility) Grievance Log does not contain this concern.) On 11/8/17 at 2:00 PM, Surveyor interviewed FM D. Surveyor asked FM D if she had been contacted by anyone else at the facility regarding this situation, she stated no. (It is important to note that FM D was not interviewed regarding this situation and she did have further information to give the facility about the alleged verbal abuse.) On 11/8/17 at 3:30 PM, Surveyor interviewed RN E about the verbalizations to R5 that she documented on 7/19/17. Surveyor asked RN E if she reported this to anyone. RN E stated she either reported it to RN F or she would have read it when she read all the notes, she could not recall. On 11/8/17 at 4:05 PM, Surveyor interviewed RN N and RS O (Rehabilitation Specialist). Surveyor asked what they could tell me about FM D's concerns. RS G stated she was on vacation, but had instructed FM D to go to RC I (Rehabilitation Coordinator) in her absence if needed. RS G stated that someone was on the phone or emailing with FM D all the time. RS G stated they offered to have a phone conference with FM D, but FM D emailed back and stated there was no need. On 11/9/17 at 11:10 AM, Surveyor interviewed AA H (Administrative Assistant) and DON B (Director of Nursing). Surveyor asked who follows up on concerns such as the one presented by FM D. AA H stated that each household handles their concerns. Surveyor asked if this concern should be present on the Household Grievance Log. AA H stated that if the issue was resolved it may not be recorded into the log. Surveyor asked what the expectation surrounding this concern would be. AA H stated to refer to RC I. On 11/9/17 at 11:25 AM, Surveyor interviewed RC I about the concern voiced by FM D. RC I voiced that multiple staff members were in contact with FM D daily. RC I stated there were emails surrounding issues with R5. Surveyor asked RC I, AA H and DON B if the verbalizations, documented on 7/19/17, were allegations of verbal abuse. RC I responded that she didn't feel it was brought up that way. Surveyor asked if there was any documentation of this allegation being investigated. RC I stated she was unsure, but she would look into it. Email, dated 7/25/17, from RC I to FM D, states that she received her email, that some items have already been addressed, that she understands her frustration with communication, that she would like to set up a meeting with RS and that she would be willing to have a discussion prior to that meeting. Email, dated 7/26/17, from FM D, responded with appreciation for responding back, that the concerns were with dignity not communication and went on to talk about being impressed with R5's progress. (It is important to note that the above two emails were the only ones presented to Surveyor.)

Based on observation, interview and policy review the facility did not ensure medication given through the gastrostomy tube for 1 out of 2 residents ([DEVICE]) was done properly. The facility's policy Enteral Care, Nutrition and Medication Administration, dated May 07, indicates when administering medications through gastrostomy feeding tubes to flush the feeding tube with 5-30cc of warm water before administering the medication and to flush the tube with 5-30cc of warm water after administration of the last medication. The nurse did not follow the policy. This is evidenced by: On 1/13/11, at 11:15 am Surveyor observed LPN (Licensed Practical Nurse) D administer Resident 8's [DEVICE] medications. LPN D gave the resident Aspirin 81mg (milligrams) [MEDICATION NAME] 300mg, and [MEDICATION NAME] 60mg. When LPN D administered the resident's medication through the [DEVICE] she did not flush the resident's [DEVICE] before or after giving the residents medication. When LPN D didn't flush before or after the medication she did not follow the facility's policy. On 1/20/11, at 1:15 pm Surveyor asked DON (Director of Nursing) B what her expectation was when LPN D gave the [DEVICE] medications. She said she would expect the LPN to flush the [DEVICE] before and after giving the medication, what if the medication wouldn't go with the feeding? On 1/20/11, at 2:00 pm LPN D told Surveyor , she knew she did not flush after giving the resident the medication and she should have.