Every finding on record at Corbin Health and Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to provide housekeeping services to ensure a clean and sanitary environment for 7 of 24 sampled residents (Resident (R)3, R14, R46, R49, R71, R78, and R79). The findings include: Review of the undated facility policy titled Protocol for Maintenance Services states that housekeeping and maintenance will maintain a sanitary, orderly, and comfortable interior and environment. It further states that any staff member can put in a work order. 1. Observation on 03/16/2026 at 9:18 AM, of R3's room revealed the wall had scuffed paint and marks on the wall. In interview with R3, at the time of observation, she stated, Those walls have been like that ever since I moved in here. I asked about it a few times, but nothing has been done to fix it. R3 further stated she had been there for almost four years; however, could not recall who she spoke to about fixing the walls. 2. Observation on 03/16/2026 at 9:26 AM, of R14's room, revealed the wall had scuff marks where the paint was missing. 3. Observation on 03/16/2026 at 9:39AM, of R46's room, revealed a black substance all over the bottom of the shower in the resident's room. 4. Observation on 03/16/2026 at 10:04 AM, of R49's room, revealed the wall had several places that had tiny holes. Further observation revealed the wall had several places that were scuffed and the paint was missing. 5. Observation on 03/16/2026 at 10:12 AM, of R71's room, revealed the paint was scuffed and missing off the wall. 6. Observation on 03/16/2026 at 10:28 AM, of R78's room, revealed several places on the wall that were scuffed and needed to be painted. 7. Observation on 03/16/2026 at 10:46 AM, of R79's room, revealed the light in the bathroom was broken and dangling down from the ceiling. Interview with the Housekeeping Manager was attempted; however, the Manager was unable to be interviewed due to being off work for vacation. In interview on 03/17/2026 at 11:42 AM, the Maintenance Director stated anyone in the entire facility could place a work order (for repairs needing to be completed). He said, We have little books that are at the nurse's stations and if anyone sees anything that needs fixed, they just fill that out and give it to me and I will take care of it. I try to prioritize what needs fixed. When asked by the State Survey Agency (SSA) Surveyor if he had any outstanding projects, he stated he did not have any at this time. In interview on 03/17/2026 at 12:13 PM, the Director of Nursing (DON) stated he was not aware of any maintenance issues with the facility. He reported anyone could place a work order. The DON further stated it was his expectation if staff saw something that needed to be fixed for them to place a work order. During interview with Housekeeping Aide 1 on 03/17/2026 at 12:37 PM, stated she had been educated, when she started, that if she saw anything needing to be fixed, she was supposed to let the nurse know and either fill out a work order or ask the nurse to fill one out. She further stated, They have instructed us to notify maintenance if we see things that need repaired when we are cleaning. In interview on 03/18/2026 at 8:17 AM, the Administrator stated it was his expectation for the facility to be kept in good condition by maintenance. He said if anyone saw anything needing to be fixed, for them to notify him or maintenance. The Administrator said, We try to do walking rounds every month where we go through the whole facility and check for things that need fixed. He further stated it was his expectation for the residents' walls to be painted and fixed if there were scuffs or marks on them.

Based on observation, interview, and review of facility policy, the facility failed to protect a resident's right to dignity for 4 of 24 sampled residents (Resident (R)44, R45, R64, R87). The findings include: Review of the facility policy titled, Policy on Foley Catheter Changes, undated, revealed there was no reference to the dignity covers for catheter bags in the policy. The policy was the only policy provided by the facility regarding Foley catheters. 1). Observation on 03/16/2026 at 10:31 AM, 03/17/2026 at 10:53 AM, 03/18/2026 at 9:20 AM, the clocks in R44's and R87's rooms were not set for the correct time. During interview on 03/16/2026 at 10:26 AM, R87 stated (regarding the clock not having the correct time), It happens sometimes. I think the batteries run down. I would like to know what time it is though. She further stated, it's behind on time. They need to put batteries in it. During interview on 03/16/2026 at 10:31 AM, R44 stated, the clock needs reset. It gets me all messed up on time. 2(a). Observation on 03/16/2026 at 9:00 AM and 3:03 PM; on 03/18/2026 at 11:52 AM; and 03/19/2026 at 10:50 AM, revealed R45 was observed to have a foley catheter with an uncovered drainage bag attached to the bedside. During interview on 03/16/2026 at 9:00 AM, R45 stated she was not sure how long her (foley catheter) bag had not had a dignity cover on it. R45 further stated the bag sure looked pretty with the little skirt on it. The resident further stated not having a cover on the catheter bag did not really bother her; however, she said she did not like other seeing the bag not covered. 2(b). Observation on 03/16/2026 at 3:03 PM, 03/18/2026 at 9:16 AM, 11:42 AM, and 03/19/2026 at 10:50 AM revealed R64 had a foley catheter with an uncovered drainage bag attached to the bedside. During interview on 3/18/2026 at 9:16 AM and 3:31 PM, R64 stated (regarding the dignity bag for the foley catheter) she would, rather have it and liked it when it was there. She said she knew the cover (for the drainage bag) had been missing as it had been torn and taken off a few days ago. R64 further stated she did not like others seeing the bag without a cover. During interview on 03/19/2026 at 2:00 PM, State Registered Nurse Aide (SRNA) 1 stated SRNA's were responsible for replacing the privacy bags for residents' catheters. He said he checked resident's (privacy) bags every morning and replaced them as needed. The SRNA reported sometimes nurses also replaced the dignity bag as needed. He further stated the supplies for replacement bags were available in the supply closet or in the medication rooms. During interview on 3/19/2026 at 2:12 PM, Licensed Practical Nurse (LPN) 2 stated she was not sure who was responsible for ensuring residents' catheter bags were covered. She further stated however, she would find out who was responsible. She said she was not aware the dignity bag covers were missing for R64 and R45. The LPN further stated all foley catheter bags should have a dignity cover. During interview on 3/19/2026 at 2:14 PM, Clinical Coordinator 1 stated all nursing staff were responsible for replacing missing/torn catheter bags. She said the bags were changed twice a month or as needed. Clinical Coordinator 1 reported If staff knew they (the bags) were missing, the bags would be changed as soon as possible. She further stated the supplies for catheter bags were available in the supply closet. She said all staff were to be aware if foley catheter cover bags were not in place. The Clinical Coordinator further stated she was not aware R45 and R64 did not having dignity bag, but they should have covers on the drainage bags at all times. During interview on 03/19/2026 at 2:26 PM, the Director of Nursing (DON) stated he expected the dignity covers for the foley catheter bags to be in place at all times to maintain the resident's dignity. He further stated the nurses were responsible for ensuring the bag covers were in place. During interview on 03/19/2026 at 3:15 PM, the Administrator stated his expectation was for the dignity covers to be in place at all times. He further stated he would also expect a torn or missing cover to be replaced quickly.

Based on observation, interview, and facility policy review, the facility failed to ensure the resident was clinically appropriate to self-administer medications for 1 of 24 sampled residents (Resident (R)23).The findings include: Review of the facility's policy titled, Administering Medication Policy, undated, revealed medication was to be administered by licensed medical or nursing personnel as prescribed. The policy further stated that self-administration of medications may be permitted when approved by the interdisciplinary team. Observation on 03/16/2026 at 3:04 PM, revealed a white, round, opened/unlabeled medication in a medication cup on R23's overbed table. During interview, at the time of observation, R23 stated the medication in the cup was Tylenol and had been left by nurse. Record review for all residents within the facility revealed the facility had no residents with medication self-administration orders. During interview 03/16/2026 at 3:24 PM, Licensed Practical Nurse (LPN) 2 stated, you don't leave opened medications with a resident because another resident could take the medication, or medication could be taken at the wrong time. She reported there had to be a doctor's order to allow medications to be left at a resident's bedside for the resident to self-administer, including Tylenol. LPN 2 said R23 did not have an order to self-administer medications. When the State Survey Agency (SSA) Surveyor asked LPN 2 about the opened medication on R23's overbed table, the LPN stated, I thought she took that, and went to R23's room to ensure R23 took the Tylenol. During interview on 03/18/2026 at 1:03 PM, Clinical Manager 1, stated, meds (medications) should not be left at bedside at any time. She said the only exception would be if there was a doctor's order for a medication to be left at bedside for the resident to self-administer. Clinical Manager 1 reported if medications were left at bedside it might interfere with other medications, or another person might take it and have a negative reaction. During interview on 03/19/2026 at 2:38 PM, the Director of Nursing (DON) stated no medications were to be left out at a resident's bedside without a physician's order. The DON reported if medications were left out without an order that should have been reported to the nursing coordinator and then to him. The DON further stated the expectation was for the facility's medication administration policy to be followed. During interview on 03/19/2026 at 3:14 PM, the Administrator stated medications should not be left at bedside without a physician's order. The Administrator further stated the expectation was that the facility's medication administration policy to be followed.

Based on interview, and review of facility documents and policy, the facility failed to establish a system to ensure thorough accounting of the disposition of all controlled drugs to enable accurate reconciliation of those drugs, which had the potential to affect those residents with narcotic medications out of the 24 total sampled residents. The findings include: Review of the facility policy titled, Protocol for Narcotic Count, undated, revealed controlled drugs were to be counted every shift by the nurse leaving and the nurse coming on duty. Further review revealed the Shift Drug Count Record was to be signed by the nurse leaving and the nurse coming on duty to signify the count was done and was correct. Review of the facility's Shift Drug Count Records for February and March 2026, revealed numerous staff signatures not documented across all four of the medication carts (indicating medication reconciliation had not consistently been documented as completed during shift change as required). Per review of the forms: the 200 Front Hall medication cart had 40 missing signatures for February 2026 and 24 missing signatures for March 1-15th. Continued review revealed the 100 Front Hall medication cart had 14 missing signatures for March 1-15th, and 24 missing signatures for February; and the 100 back hall medication cart had 22 missing signatures for February. Further review of the records revealed the review of the drug count records and the copies provided by the facility on 03/17/2026, had added signatures that were not on the records at the original review. During interview on 03/16/2026 at 4:04 PM, Licensed Practical Nurse (LPN) 4 stated on hand-off of the medication carts at shift change, two licensed staff were to reconcile the narcotic counts and both were to sign the counts to indicate they were correct. LPN 4 further stated it was important to sign the narcotic sheets to help protect themselves and the residents from misappropriation of narcotic medications. During interview on 03/19/2026 at 2:47 PM, Clinical Coordinator 1 stated she collected the Shift Drug Count Records monthly and those records were stored in her office, and at some point went to medical records. The Clinical Coordinator reported she was not sure if checking the narcotic records to ensure they were complete was her responsibility; however, she said she probably should be checking to see if they were complete. She stated her expectation was for each staff member to complete the count at shift change, and to sign the narcotic count as completed. Clinical Coordinator 1 further stated not signing off the completed counts could cause issues if medications were missing. During interview on 03/19/2026 at 2:26 PM, the Director of Nursing (DON) stated two licensed nurses were to sign off on the narcotics sheet upon hand-off of the medication cart at shift change. He said If any discrepancy was noted staff were to immediately contact the on-call administration person. The DON reported not signing off on the narcotic count sheet at hand-off of the cart could cause significant issues if medications were missing. He explained the Clinical Coordinators were responsible for oversight to ensure the staff signatures were completed as required. He stated he did not perform oversight; however, said he would trust his staff responsible for doing that would ensure it was done. The DON further stated not checking to ensure completion of the narcotic count records could cause issues regarding missing narcotics and inability to track the narcotics. During interview on 03/19/2026 at 3:15 PM, the Administrator stated her expectation was for two staff to count narcotics, and both sign the narcotic count sheet attesting that the counts were correct as required. The Administrator further stated he should have been providing oversight to ensure the narcotic counts were being performed and documented as required.

The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure its personnel handled, stored, processed, and transported linens so as to prevent the spread of infection which had the potential to affect residents using the facility's protective underpads. Additionally, the facility failed to ensure necessary environmental cleaning and disinfection for 2 of 24 sampled residents (Resident (R)53 and R90). The findings include: Review of the facility policy titled, Infection Prevention & Control Program Policy, undated, revealed personnel were to handle, store, process, and transport linens i(n a manner) to prevent the spread of infection. Continued review revealed bowel and bladder incontinence was noted as a high risk for infection conditions and the facility should have personal protective equipment (PPE) available to all staff to keep them as free from body fluid contamination as possible. 1). Review of R53's and R90's Kardex (care plan for aides) showed both residents required supervision or assistance for toilet use. R53's Kardex noted he was incontinent at times. Observation on 03/16/2026 at 10:18 AM, revealed multiple briefs soiled with a yellowish substance in R53's and R90's bathroom in a garbage can. Further observation revealed there was no garbage bag in the can. During interview on 03/16/2026 at 10:23 AM, Housekeeping Aide 2 stated the State Registered Nursing Aides (SRNA's) were responsible for removing soiled briefs from residents' rooms. The Housekeeping Aide further stated the SRNA's were to replace residents' garbage bags as needed. During interview on 03/18/2026 at 9:31 AM, SRNA 5, stated SRNA's were to remove soiled briefs immediately after finishing with resident care. She reported SRNA's were responsible for disposing of soiled briefs. SRNA 5 further stated the SRNA's should take garbage bag and all when dealing with soiled briefs. During interview on 03/18/2026 at 3:34 PM, Clinical Manager 1 stated SRNA's were to take care of disposing of soiled briefs. The Clinical Manager further stated for residents' rooms (of residents who changed their own briefs) the SRNA's were to check those rooms every two hours. 2). Observation on 03/17/2026 at 9:10 AM, revealed Laundry Aide 1, touched her full chest, stomach area, and upper legs with clean protective underpads as she was folding them. During interview on 03/17/2026 at 9:20 AM, Housekeeping Aide 1 stated the laundry aides did not have any type of PPE they wore while separating dirty clothing. The Housekeeping Aide reported there was no way to ensure the clean laundry was not being contaminated by the dirty clothing since the laundry aides wore no PPE. Housekeeping Aide 1 further stated the laundry aides had not had PPE available to use in several years.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were protected from physical abuse for three (3) of eight (8) sampled residents (Residents #1, #6, #7). 1) On [DATE], Licensed Practical Nurse (LPN) #2 struck Resident #1 with his/her fist resulting in Resident #1 having an injury to his/her right eye. Resident #1 had to be taken to the emergency room for further evaluation and was later admitted . 2) On [DATE] Resident #6 slapped Resident #7 on the face while waiting to go outside to smoke, then in return, Resident #7 slapped Resident #6 on the face. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR S483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR S483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation, revised on ,d+[DATE], revealed the facility did not condone or tolerate resident abuse (this included verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals. Per the facility's policy, abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse included hitting, slapping, pinching and kicking. 1) Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed Resident #1 had a laceration to his/her right cheekbone, under the eye area. The resident's Responsible Party (RP) was notified on [DATE] at 11:50 PM and the resident's physician was notified on [DATE] at 12:15 AM. Continued review revealed the physician had provided wound care orders for the laceration. Further review revealed a handwritten statement by RN #2 which stated, I was called to the shower room by Licensed Practical Nurse (LPN) #2 and when entering the room, Resident #1 was bleeding and verbally upset saying to LPN #2 that it's not over, I'm gonna get you. Ongoing review of the report revealed a small laceration was noted to the resident's cheek bone, under the resident's eye area to the right eye. Continued review revealed, as the shift was ending Certified Nurse Assistant (CNA) #1 called RN#2 and reported LPN #2 told her to say Resident #1 head butted him; however, CNA #1 told RN#2 she had not told the truth about what had occurred. CNA#1 then stated she saw Resident #1 hit at LPN #2, then LPN #2 hit the resident in the face causing a cut under Resident #1's right eye. LPN #2 then told CNA#1 to say Resident #1 had head butted LPN #2 causing the eye injury. Closed Record Review revealed the facility admitted Resident #1 on [DATE] with diagnoses that included: Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Score of ninety-nine (99), which indicated the resident was cognitively impaired. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of Resident #1's care plan, last revised [DATE], revealed the resident had potential for alteration in mood/behaviors due to dementia; had a history of becoming combative with staff at times when attempting to redirect with a goal to include the resident would be free from altercations in mood/behaviors due to diagnosis of dementia with behaviors. Further review of the care plan revealed interventions included: anticipate/ meet needs timely, if resists care, allow to calm down and then reproach for care, talk with resident during care and allow/encourage resident to vent feelings, and staff to back away from resident when he/she becomes combative let him/her calm down before transfers. Review of Resident #1's Psychiatry Progress Notes from [DATE] - [DATE], electronically signed by the Nurse Practitioner (NP), revealed staff reported resident exhibited resistance and combativeness towards staff during care. Further review revealed staff reported the resident received assistance with all Activities of Daily Living (ADL's). Review of a local Police Department Report, dated [DATE] to [DATE], revealed on Friday, [DATE]th, 2022, at approximately 11:00 PM, the perpetrator (LPN #2) struck the victim (Resident #1) in the right eye with his fist causing the victim (Resident #1) minor visible injury. Continued review revealed LPN #2 was interviewed by law enforcement on [DATE] and was served a criminal arrest warrant on [DATE] at 12:32 PM. Review of a Facility's Investigative Summary, dated [DATE], revealed Resident #1 was transferred to the local hospital for further evaluation and treatment. Continued review revealed all staff, except those on Family Medical Leave Act (FMLA) were interviewed about abuse or mistreatment of any resident, and if they had ever witnessed LPN #2 or anyone else abuse or mistreat a resident. Further review revealed LPN #2 was suspended then terminated and was charged with Fourth Degree Assault by local law enforcement. Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed she was called to the shower room by LPN #2 and when entering the room, Resident #1 was bleeding and verbally upset saying, it's not over, I'm gonna get you. Review of an interview statement with CNA#1, dated [DATE], conducted by Clinical Nurse Consultant (CNC) after the incident occurred, revealed CNA #1 had asked LPN #2 to assist her in the shower room with Resident #1. CNA #1 stated the resident was calm until they attempted to remove Resident #1's shirt. When the shirt was being removed Resident #1 hit at LPN #2, then LPN #2 hit Resident #1 in face/eye area with his fist causing a cut under Resident #1's right eye. CNA #1 stated LPN #2 told her she would have to write a statement saying Resident #1 head butted LPN#2, which caused Resident#1's face/eye injury. CNA #1 stated she asked the LPN why and he did not respond. CNA #1 stated she was scared and intimidated by LPN #2 and that was the reason she did not tell the truth about the incident initially. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct for an interview. During a telephone interview with LPN #1 on [DATE] at 3:16 PM, she stated she was on call the night of [DATE] and received a call from LPN #2, reporting the accident with Resident #1 in the shower room. She stated LPN #2 reported Resident #1 had become combative and had head butted nurse. LPN #1 stated she asked if Resident #1 had an injury and was told only small discoloration. During an interview with RN #1 on [DATE] at 4:15 PM, revealed she was working day shift on [DATE], and received report from RN #2, who reported Resident #1 had head butted someone in the shower. RN #1 stated she looked over Resident #1 and saw his/her right eye was black and bruising way down to his/her cheek and his/her eye was almost swollen shut. RN #1 stated Resident #1 needed to go to the ER (emergency room ) as she feared resident could have a facial fracture. Continued interview revealed about thirty (30) to forty-five (45) minutes into the shift, CNA #1 was at the nurses' station speaking with RN#2, informing her of LPN #2 hitting Resident #1. RN #1 stated she called the DON and then Resident #1's spouse, informing him/her of resident being transferred to the local hospital. During an interview with RN #2, on [DATE] at 1:33 PM, she stated she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under his/her right eye and LPN #2 stated the resident had head-butted him while he was attempting to remove resident's shirt. RN #2 stated she performed first aide to the resident. In a continued interview, she stated at the end of shift, CNA #1 was crying and told RN #2 of LPN #2 using his fist and punched the resident in the eye and had told her to stick to the story of the resident head-butting him. RN #2 stated she contacted the DON immediately and was also getting other staff to check to make sure LPN #2 was off the property. On [DATE] at 2:38 PM and at 5:14 PM, a telephone interview was attempted with LPN #2, however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. Interview with the Director of Nursing (DON) on [DATE] at 4:49 PM revealed he received a call early morning of [DATE] from LPN #1, reporting an abuse incident. The DON stated he made calls to the facility's management team and started an investigation. Continued interview revealed CNA #1 was employed by a staffing agency who was contracted with the facility. Further interview revealed CNA #1 had attended abuse training from facility staff prior to working a scheduled shift. Continued interview with the DON revealed CNA #1 stated she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 reported immediately the false story of the Resident #1 head butting LPN #2 but did not report LPN #2 hitting Resident #1 and therefore, did not follow the facility's abuse policy. During an interview with the Administrator on [DATE] at 9:47 AM, he stated he was out of town on the date of the event and was made aware of the abuse allegation on [DATE] by the DON. Continued interview with the Administrator he stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. 2) Review of the facility's incident Report, dated [DATE] at 1:15 PM, revealed CNA #7 reported while he was taking the residents outside for a smoke break, Resident #6 attempted to go too, and Resident #7 told Resident #6 he/she could not go because he/she did not smoke. Resident #6 slapped Resident #7 on the face, then Resident #7 slapped Resident #6 on the face. Both residents were separated and assessed to have no injuries. Both residents were placed on 1:1 with staff until seen by psychiatric (psych) services. a) Review of Resident #6's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Traumatic Brain Injury (TBI), Dementia, Major Depressive Disorder, History of Transient Ischemic Attack (TIA); and Cognitive Communication Deficit. Review of Resident #6's Significant Change MDS, dated [DATE], revealed the facility had assessed the resident to have e BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitive impaired. Continued review revealed the resident had difficulty focusing attention and had disorganized thinking behavior present that fluctuates, which comes and goes. Further review revealed Resident #6 did not have any behaviors indicated. Continued review revealed, under the section for Preferences for Customary Routine and Activities, the resident preferred doing things with groups of people. A review of Physician Orders effective [DATE] revealed Resident #6 was prescribed Mirtazapine 15 milligram (mg) every hour of sleep; Sertraline 25 mg QD; and Memantine 10 mg by mouth twice. Review of a skin assessment dated [DATE] revealed Resident #6 had no injuries noted. Observation of Resident #6, on [DATE] at 1:05 PM, revealed the resident was sitting in the wheelchair in his/her room. The State Survey Agency (SSA) Surveyor attempted an interview with the resident, but the resident's speech was incoherent and garbled. b) Review of Resident #7's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Bipolar Disorder, Major Depressive Disorder, Obsessive-Compulsive Disorder, and Anxiety Disorder. Review of a Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed Resident #7 had no indication of delirium or behaviors indicated. Review of Nurses Note dated [DATE] revealed the resident was assessed by psych service and no new orders were given by the Advanced Practice Registered Nurse (APRN). Review of Nurses Note dated [DATE] at 1:25 PM, revealed the resident had an altercation with another resident (Resident #6) related to Resident #6 attempted to follow Resident#7 out on smoke break. Resident #7 told Resident #6 you cannot go, resulting in Resident #6 slapping Resident #7 on the face. Resident #7 retaliated by slapping Resident#6 on the face. During an interview with Resident #7, on [DATE] at 2:30 PM, the resident stated he/she was allowed to go out and smoke six (6) times a day. Resident #7 stated We were all gathered at the doorway waiting for staff to bring the cigarettes and take us out. She stated Resident #6 was unstable and he/she started to come outside and he/she knew the resident was not allowed outside, so she blocked the doorway with his/her arms and told Resident #6 he/she could not go out and Resident #6 slapped me across the face. Per the interview, she stated she did not think about it but then slapped the resident back. Further, the resident stated she could not recall if staff was around at the time of the incident. During a telephone interview with CNA #5 (Agency) on [DATE] at 1:24 PM, he stated he remembered the event but not vividly. CNA#5 stated he could not remember the exact verbal exchange between the two residents and he was trying to get between the two residents. CNA #5 stated he did not recall Resident #6 slapping Resident #7, but he thought Resident #6 may have pushed the other resident, then Resident #7 slapped Resident #6. CNA #5 further stated he was agency staff and was not familiar with Resident #6 and Resident #7's previous behaviors. He also stated while attempting to intervene in the altercation between Resident #6 and Resident #7, Resident #6 reached around him and was able to hit Resident #7. During an interview with the Director of Nursing (DON ) on [DATE] at 10:41 AM, she stated Resident #6 was in the process of being redirected when the altercation occurred The DON stated it was his expectation that all staff followed the facility's abuse policy. During an interview with the Administrator, on [DATE] at 11:44 AM, he stated he expected staff to follow the facility's policy. Per the interview, he stated the CNA followed the policy because the CNA was in the process of intervening but was not successful. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the emergency room . Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital emergency room . During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an allegation of physical abuse was reported to the State Agencies and local law authorities immediately, but no later than two (2) hours after the allegation was made for one (1) out of eight (8) sampled residents (Resident #1). On [DATE], LPN #2 struck Resident #1 with his/her fist resulting in Resident #1 having an injury to his/her right eye. Certified Nursing Assistant (CNA) #1 reported to Registered Nurse (RN) #1 that the resident initially head-butted LPN #2; however, later reported to RN #2 that LPN #2 had physically abused Resident #1 by hitting the resident with his fist. The CNA's failure to report timely allowed LPN #2 continued access to Resident #1, to potentially abuse the resident further, and all of the other facility residents, which was the facility's failure to ensure the residents were protected from abuse. The facility's failure to report allegations of abuse has caused or is likely to cause serious injury, Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR S483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR S483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of Abuse, Neglect, Misappropriation and Exploitation Policy, undated, revised ,d+[DATE], revealed all allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the Director of Nursing and/or the Administrator of the facility. Continued review revealed that if the Administrator or Director of Nursing were not in the facility, the person making the allegation would immediately call the Supervisor on Call as listed at each nurses' station. Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed Resident #1 had a laceration to his/her right cheekbone, under the eye area. Further review revealed a handwritten statement by RN #2 which stated, I was called to the shower room by Licensed Practical Nurse (LPN) #2 and when entering the room, Resident #1 was bleeding and verbally upset saying to LPN #2 that it's not over, I'm gonna get you. Ongoing review of the report revealed a small laceration was noted to the resident's cheek bone, under the resident's eye area to the right eye. Continued review revealed, as the shift was ending Certified Nurse Assistant (CNA) #1 called RN#2 and reported LPN #2 told her to say Resident #1 head butted him; however, CNA #1 told RN#2 she had not told the truth about what had occurred. CNA#1 then stated she saw Resident #1 hit at LPN #2, then LPN #2 hit the resident in the face causing a cut under Resident #1's right eye. LPN #2 then told CNA#1 to say Resident #1 had head butted LPN #2 causing the eye injury. Review of Resident #1's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses which included: Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 99, which indicated the resident was unable to complete the interview. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of a facsimile confirmation sent to The Office of Inspector General (OIG), revealed it had been sent on [DATE] at 11:53 AM, by the Director of Nursing (DON). However, the incident occurred on [DATE] at 11:00 PM. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct an interview. During an interview with RN #1, on [DATE] at 4:15 PM, she stated Certified Nursing Assistant (CNA) #1 recanted the story she first told RN #1. She stated the CNA originally reported the resident had head butted Licensed Practical Nurse (LPN) #1; however, later reported LPN #2 had hit the resident with his fist. Per the interview, the CNA waited until about forty-five (45) minutes in her shift to repot the allegation of abuse. RN #1 stated she called the Director of Nursing (DON) to inform her of the reported allegation of abuse. During an interview with RN #2, on [DATE] at 1:33 PM, she stated she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under right eye and LPN #2 stated resident had head-butted him while he was attempting to remove resident's shirt. In a continued interview, RN #2 stated that at the end of the CNA's shift CNA #1 was crying and told RN #2 that LPN #2 had physically abused the resident, by punching the resident in the eye with his fist. RN #2 stated she contacted the DON immediately and was also getting other staff to check to make sure LPN #2 was off the property. On [DATE] at 2:38 PM at 5:14 PM, a telephone interview was attempted with LPN #2; however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. In an interview with the DON on [DATE] at 4:49 PM, revealed he received a call on the morning of [DATE] from LPN #1, who was on call for the facility during the time of the incident. She stated, LPN #1 told the DON the incident involving Resident #1 had not been reported truthfully by CNA #1. The DON then stated, LPN#1 said Resident #1 had not head butted LPN#2 as originally reported. Per interview, LPN #1 told the DON LPN#2 hit Resident #1 in the face with his fist causing the injury to the right eye. The DON stated the facility's investigation revealed CNA #1 reported she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 reported immediately the false story of the Resident #1 head butting LPN #2 but did not report LPN #2 hit Resident #1, and therefore, did not follow the facility's abuse policy. The DON stated CNA #1 could have went to the other side of the facility, to the bathroom, or even to her car to make a telephone call to report the abuse she had witnessed. The DON further stated it was his expectation that staff follow the facility's Abuse Policy. During an interview with the Administrator, on [DATE] at 9:47 AM, he stated he was out of town on the date of the incident and was made aware of the abuse allegation on [DATE] by the DON. The Administrator stated all staff have been educated on abuse and were expected to report immediately . Further, the Administrator stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the emergency room . Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital emergency room . During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for three (3) of eight (8) sampled residents (Resident #1, Resident #6, Resident #7) that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. 1). On [DATE], Resident #1 was combative during care and LPN #2 struck Resident #1 with his fist resulting in Resident #1 having an injury to his/her right eye. Review of the resident's care plan revealed staff should have backed away from resident when he/she becomes combative let him/her calm down. However, the staff member failed to implement the resident's Person-Center Comprehensive Care Plan when the resident became combative during care. 2). On [DATE] Resident #6 slapped Resident #7 on the face while waiting to go outside to smoke, then Resident #7 slapped Resident #6 on the face. a) Review of the Resident #6's care plan revealed staff were to provide the resident an organized, structured environment. However; interviews and record review revealed the resident followed the smokers outside for their smoke break and the facility staff failed to assist the resident, causing a physical altercation. b) Review of Resident #7's care plan revealed staff were to provide one-to-one supervision (1:1) when the resident had increased mood and behavior. However, when the resident blocked Resident #7 from exiting the courtyard door, the facility failed to increase the resident's supervision and monitoring, to include 1:1 supervision, to prevent the physical altercation. The facility's failure to ensure resident care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR S483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR S483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy Care Plan Policy & Protocol, revised ,d+[DATE], revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Continued review revealed the Kardex would also be utilized as a guide for the Nurse Aides in providing care on a daily basis. Continued review of the policy revealed it was a working tool and revisions would be made when indicated. As part of the care plan, the Nurse Aide Kardex (an overview of each residents care needs) would reflect person-centered care preferences 1. Review of Resident #1's Admission Record revealed the facility admitted the resident on [DATE] with diagnosis to include Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of ninety-nine (99), which indicated the resident was cognitively impaired. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of Resident #1's care plan, last revised [DATE], revealed the resident had potential for alteration in mood/behaviors due to dementia; had a history of becoming combative with staff at times when attempting to redirect with a goal to include the resident would be free from altercations in mood/behaviors due to diagnosis of dementia with behaviors. Interventions included: anticipate/ meet needs timely, if resistive to care, allow to calm down and then reapproach for care, talk with resident during care and allow/encourage resident to vent feelings, and staff to back away from resident when he/she becomes combative let him/her calm down before transfers. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct an interview. During an interview with RN #1, on [DATE] at 4:15 PM, she stated she was working day shift [DATE], and received report from RN #2, who reported Resident #1 had head butted someone in the shower. RN #1 stated she looked over Resident #1 and saw his/her right eye was black and bruising way down the cheek and eye was almost swollen shut. RN #1 stated Resident #1 needed to go to the ER (emergency room ) as she feared the resident could have a facial fracture. Continued interview revealed about thirty (30) to forty-five (45) minutes into the shift, CNA #1 was at the nurses' station speaking with RN#2, informing her of LPN #2 hitting Resident #1. Per the interview, RN#1 stated Resident #1 would become agitated at times and staff should have walked away and reapproached the resident at a later time to allow the resident time to calm down. She further stated LPN #2 should have followed the Care Plan. During an interview with RN #2 on [DATE] at 1:33 PM she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under right eye and LPN #2 stated resident had head-butted him while he was attempting to remove resident's shirt. RN #2 performed first aide to resident. Continued interview revealed at end of shift, CNA #1 was crying and told RN #2 of LPN #2 used his fist and punched the resident in the eye. Further, RN#2 stated Resident #1 would become agitated with care and staff should have walked away to allow the resident time to calm down. She further stated LPN #2 should have followed the Care Plan. On [DATE] at 2:38 PM and at 5:14 PM, a telephone interview was attempted with LPN #2, however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. Interview with the DON, on [DATE] at 4:49 PM, revealed he received a call on the morning of [DATE] from LPN #1, who was on call for the facility during the time of the incident. She stated, LPN #1 told the DON the incident involving Resident #1 had not been reported truthfully by CNA #1. The DON then stated, LPN#1 said Resident #1 had not head butted LPN#2 as originally reported. Per the interview, .LPN #1 told the DON LPN#2 hit Resident #1 in the face with his fist causing the injury to the right eye. The DON stated the facility's investigation revealed CNA #1 reported she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 could have went to the other side of the facility, to the bathroom, or even to her car to make a telephone call to report the abuse she had witnessed. The DON further stated staff should have intervened and redirect when necessary to protect the residents, and it was his expectation that staff follow the facility's policy. During an interview with the Administrator, on [DATE] at 9:47 AM, he stated he was out of town on date of event and was made aware of the abuse allegation on [DATE] by the DON. Continued interview with the Administrator, he stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. 2. Review of the facility's incident Report, dated [DATE] at 1:15 PM, revealed CNA #7 reported while he was taking the residents outside for a smoke break, Resident #6 attempted to go too, and Resident #7 told Resident #6 he/she could not go because he/she did not smoke. Resident #6 slapped Resident #7 on the face, then Resident #7 slapped Resident #6 on the face. Both residents were separated and assessed to have no injuries. Both residents were placed on 1:1 with staff until seen by psychiatric (psych) services. a.) Review of Resident #6's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Traumatic Brain Injury (TBI), Dementia, Major Depressive Disorder, History of Transient Ischemic Attack (TIA); and Cognitive Communication Deficit. Review of Resident #6's Significant Change MDS dated [DATE], revealed the facility had assessed the resident to have e BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitive impaired. Continued review revealed resident had difficulty focusing attention and had disorganized thinking behavior present that fluctuates, which comes and goes, changes in severity. Further review revealed Resident #6 did not have any behaviors indicated. Continued review revealed Preferences for Customary Routine and Activities resident prefers doing things with groups of people. Review of Resident #6's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned for alternation in cognition related to the resident's displayed modified independent decision making. Continued review revealed on [DATE] handwritten problem for: noted BIMS 02, indicating severely impaired cognitive function, inattention and disorganized thinking, noted with difficulty following tasks/directions, with a goal the resident would be maintained in a safe environment while working against further cognitive decline. Interventions included: be aware the resident may use non-verbal gestures such as nodding, pointing, etc. in effort to communicate a want/need; give clear, simple directions as needed/indicated; observe for improvement or decline in cognition; provide an organized, structured environment with consistency in care. Continued review revealed resident had potential for fear/anxiety and new intervention added on [DATE] of resident placed 1:1 until seen by psych services. The facility; however, failed to ensure the resident's care plan was implemented to provide an organized, structured environment that was consistent with the resident's care, due to his/her cognitive decline. b.) Review of Resident #7's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Bipolar Disorder, Major Depressive Disorder, Obsessive-Compulsive Disorder, and Anxiety Disorder. Review of a Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed Resident #7 had no indication of delirium or behaviors indicated. Review of Resident #7's Comprehensive Care Plan, initiated [DATE], revealed the resident was care planned for potential alteration in mood/behavior state related to a history of hypoxic encephalopathy, depression, anxiety, agitation, psychosis, paranoid delusional disorder. Further review revealed the resident becomes anxious at times and has to be redirected, has a history of noncompliance with staff, becoming easily agitated, cursing at staff or other residents with a goal to include the resident would remain free of mood indicators and would have a decrease in behaviors this assessment period. Interventions included: call the residents brother as needed as he was good at redirecting the resident; encourage resident to attend special events, functions and activities to socialize and elevate mood, instruct resident on inappropriate behaviors as needed, provide diversional activities as needs, listening to music, talking/ visiting with male friend, offer 1:1 during mood/behaviors, establish a trusting relationship with resident and encourage him/her to verbalize feelings, psych as needed and resident enjoys going outside to courtyard, assist as needed. Observe whereabouts frequently while in courtyard. The facility; however, failed to ensure staff implemented the resident's care plan to provide increased supervision, such as 1:1, when the resident blocked the doorway with his/her arms preventing Resident #6 from going outside with the other resident. Review of Nurses Note, dated [DATE] at 1:25 PM, revealed the resident had an altercation with another resident (Resident #6) related to Resident #6 attempted to follow Resident#7 out on smoke break. Resident #7 told Resident #6 you cannot go, resulting in Resident #6 slapping Resident #7 in the face. Resident #7 retaliated by slapping Resident#6 in the face. During an interview with Resident #7, on [DATE] at 2:30 PM, the resident stated he/she was allowed to go out and smoke six times a day. Resident #7 stated We were all gathered at the doorway waiting for staff to bring the cigarettes and take us out. The resident stated Resident #6 was unstable and was not allowed outside. The resident stated he/she knew Resident #6 was not allowed outside, so he/she blocked the doorway with his/her arms and told the resident he/she could not go out. Resident #7 stated Resident #6 slapped him/her across the face. Without thinking about it, Resident #7 stated he/she slapped Resident #6 back. The resident further stated he/she could not recall if any staff were around at the time of the incident. During a telephone interview with CNA #5 (Agency), on [DATE] at 1:24 PM, he stated he remembered the event but not vividly. CNA#5 stated he could not remember the exact verbal exchange between the two residents and he was trying to get between the two residents. CNA #5 stated he did not recall Resident #6 slapping Resident #7, but he thought Resident #6 may have pushed the other resident, then Resident #7 slapped Resident #6. CNA #5 further stated he was agency staff and was not familiar with the past behaviors of Resident #6 and Resident #7. He also stated while attempting to intervene in the altercation, Resident #6 reached around him and hit Resident #7. Per the interview, the CNA stated the Kardex and Resident Care Plan instructed him on how to care for the residents and it should be followed. During an interview with the DON, on [DATE] at 10:41 AM, he stated Resident #6 was in the process of being redirected when the altercation happened. The DON stated staff were attempting to follow the the care plan when the CNA tried to redirect the residents but could not stop the altercation. During an interview with the Administrator, on [DATE] at 11:44 AM, he stated it was his expectation that staff followed the facility's Care Plan Policy to ensure all residents received the care they required. The Administrator stated he felt the CNA had followed the care plan and was attempting to intervene when the altercation occurred. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the emergency room . Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital emergency room . During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to review/revise the comprehensive care plan for one (1) of five (5) sampled residents (Resident #1). Interviews and record reviews revealed staff identified a red non-blanchable (redness that persists when pressure is applied) area to the residents' left middle finger on 12/10/2021. However, review of the resident's care plan revealed the care plan was not reviewed/revised to include interventions to prevent pressure ulcer development for the resident. Observations of Resident #1 conducted on 01/11/2022 at 4:15 PM revealed a non-blanchable area measuring 1.5 centimeters (cms) wide and 1.6 cm's long was observed to the resident's left middle finger. The findings include: Review of the facility policy titled Care Plan Policy & Protocol last revised September 2017, revealed staff would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a residents medical, nursing and mental needs. The policy also stated the resident's care plan should be reviewed/revised periodically, which included when a change in a resident's condition was identified. Review of the facility policy titled Skin Ulcers/Injuries dated September 2018 revealed at least one time a week, residents should receive a head to toe assessment and all unusual skin conditions would be noted which included pressure areas (stage one through stage four, unstageable and deep tissue injuries). According to the policy, a stage one (1) pressure sore (ulcer) was defined as intact skin with non-blanchable redness of a localized area. The policy also stated nursing measures to prevent pressure ulcers/injuries would be followed for facility residents which included inspect potential sites of breakdown at least once a day, and to use pressure reducing devices as indicated. Review of Resident #1's medical record revealed the facility admitted the resident on 06/24/2019 with diagnoses which included Unspecified Paralytic Syndrome and Contracture of Muscle. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he/she was totally dependent on two (2) staff members for transfers and he/she had functional limitations in range of motion to both sides of his/her upper/lower extremities. The MDS also indicated Resident #1 was at risk for developing pressure ulcers and staff determined he/she had one (1), stage two (2) pressure ulcer. Review of the assessment also revealed Resident #1 was severely cognitively impaired and was not interviewable with no BIMS score assessment completed for the resident. Review of Resident #1's skin integrity assessment dated [DATE] indicated staff identified he/she had non-blanchable redness to the residents' left middle finger, due to pressure from his/her thumb and index finger, secondary to the residents' hand/finger contractures. Resident #1's skin integrity assessment forms dated 12/17/2021, 12/24/2021 and 12/31/2021, further indicated blanchable redness continued to be observed to his/her left middle finger due to pressure from the resident's left index finger. Review of Resident #1's comprehensive care plan last reviewed/revised on 11/23/2021 indicated staff determined on 08/31/2021 the resident had contractures to his/her bilateral upper extremities, and had a potential for alterations in skin integrity/pressure ulcer development due to his/her physical limitations and limited mobility. Continued review of the care plan revealed staff implemented interventions which included placing carrots (a soft carrot shaped device) in Resident #1's hands, assess the residents skin weekly, provide the resident with a pressure reduction mattress and a cushion to his/her chair. Further review of interventions to prevent pressure ulcer development for Resident #1 revealed staff would keep his/her call light within reach, observe his/her skin during morning care and alert the nurse of any changes, inform his/her physician as needed, reposition him/her every two hours and as needed and assist him/her with activities of daily living. Even though staff identified non-blanchable/blanchable redness to Resident #1's left middle finger on 12/10/2021, 12/17/2021, 12/24/2021 and 12/31/2021 the care plan provided no evidence staff implemented interventions to prevent the development of pressure ulcers for the resident. Observations of Resident #1 on 01/11/2022 at 4:15 PM revealed his/her left hand/fingers were contracted and pressure was being applied to his/her left middle finger due to the resident's contracture. Observations also revealed staff placed carrots in both of his/her hands; however, staff failed to implement interventions that provided pressure relief to the residents fingers due to contractures, to prevent the development of pressure ulcers. Further observations of Resident #1 on 01/11/2022 with Licensed Practical Nurse (LPN) #1 revealed a slow to blanch/red area that measured 1.5 centimeters (cm's) wide and 1.6 cm's long was observed the residents left middle finger. Resident #1 was not able to be interviewed during the observations, because of his/her cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1, on 01/11/2022 at 4:15 PM, revealed the red/slow to blanch area had been identified to Resident #1's left middle finger a while back. The LPN also stated Resident #1 had a history of pressure ulcers to his/her left index finger and stated I should have put something in place to prevent that red area from becoming a pressure sore but I didn't. The LPN stated staff nurses had been trained to review/revise care plans and implement interventions when abnormal skin conditions were identified to prevent pressure ulcers; however, stated she was unable to recall why she had failed to implement an intervention for Resident #1. Interview with Clinical Coordinator (CC) #1, on 01/13/2022 at 10:50 AM, revealed nurses should review/revise resident care plans and ensure interventions were implemented to prevent the development of pressure ulcers for facility residents when abnormal skin concerns were identified. The CC also stated when staff nurses identified/documented red, slow to blanch areas to Resident #1's left finger, due to pressure caused from his/her contractures, his/her plan of care should have been revised to include interventions to prevent pressure ulcers for the resident. Interview with MDS nurse #1, on 01/13/2022 at 12:10 PM, revealed staff nurses were expected to review/revise care plans and implement effective interventions when abnormal skin conditions are identified to prevent pressure ulcers. She also stated when blanchable and non-blancable areas were observed to Resident #1's left middle finger interventions should have been implemented to prevent the development of pressure ulcers for the resident. Interview with the Director of Nursing (DON), on 01/12/2022 at 10:45 AM, revealed staff implemented the carrots to be placed in Resident #1's hands due to the pressure caused by the residents' contractures. However, he acknowledged the carrot device provided no relief of pressure and failed to prevent the development of pressure ulcers for the residents' fingers. According to the DON, nurses were required to conduct weekly head to toe skin assessments for residents and if skin concerns were identified, the residents care plan should be reviewed/revised to include interventions to prevent the development of pressure ulcers for the residents. The DON also stated when staff identified the red/slow to blanch areas to Resident #1's left finger due to his/her contractures, his/her care plan should have been revised to include effective interventions to prevent the development of pressure ulcers for the resident. Interview with the Administrator, on 01/13/2022 at 2:40 PM, revealed nurses were required to conduct weekly assessments of the residents' skin and if skin impairment concerns were identified, the plan of care should be revised to include interventions to prevent the development of pressure ulcers. He also stated, when staff identified red/slow to blanch areas to Resident #1's left middle finger, his/her care plan should have been revised to include effective interventions in attempts to prevent the development of pressure ulcers for the resident.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #1), received necessary care and services to maintain appropriate grooming. The facility assessed Resident #1 to be totally dependent on staff to meet his/her personal hygiene needs. Observations of Resident #1's teeth on 01/11/2022 revealed a thick yellow/brown substance was observed on the resident's upper and lower teeth. The findings include: Review of the facility policy titled Protocol for Oral Hygiene undated revealed residents would receive oral care/oral hygiene every shift and as indicated. According to the policy, if residents were not able to perform their own oral care, staff would provide oral care to the resident every shift and as needed. Review of Resident #1's medical record revealed the facility admitted the resident on 06/24/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on two (2) staff members for personal hygiene needs and the assessment also indicated he/she had functional limitations in range of motion to both sides of the residents upper/lower extremities. The MDS also revealed Resident #1 was severely cognitively impaired; therefore, staff were unable to complete an interview with the resident to determine a brief interview for mental status (BIMS) score. Observations of Resident #1 on 01/11/2022 at 11:30 AM, 1:40 PM and 4:15 PM, revealed a thick yellow/brown substance was observed on the resident's upper and lower teeth. Continued observations revealed both of Resident #1's elbows and both of his/her hands/fingers were contracted. Interview with State Registered Nurse Aide (SRNA) #1, on 01/11/2022 at 1:40 PM, revealed she was assigned to care for Resident #1 during the day shift on 01/11/2022 (since approximately 7 AM). The SRNA acknowledged Resident #1 had a thick yellow/brown substance on his/her upper/lower teeth and the resident was unable to provide his/her own oral care. The nurse aide stated she had been trained to provide oral care to residents at least once a shift and more often, if needed; however, stated she had not provided oral care for Resident #1 during her shift on 01/11/2022 but stated she should have. She stated she had been busy and forgot to provide oral care to Resident #1 as required. Interview with SRNA #2, on 01/11/2022 at 3:50 PM, revealed she assisted SRNA #1 with providing incontinent care to Resident #1 during the day shift (7 AM-7 PM) on 01/11/2022. The SRNA stated Resident #1's teeth need to be brushed and had observed the yellow/brown substance on the resident's upper and lower teeth on 01/11/2022. SRNA #2 stated Resident #1 should have been provided oral care and his/her teeth should have been brushed, when the residents morning care was provided by his/her assigned nurse aide, at the beginning of the shift on 01/11/2022. Interview with Licensed Practical Nurse (LPN) #1, on 01/11/2022 at 4:15 PM, revealed she was assigned to care for Resident #1 during the day shift on 01/11/2022. The nurse conducted a skin assessment (while the surveyor observed) and acknowledged Resident #1's teeth were soiled in appearance and he/she was in need of oral care. The nurse also stated she was responsible to ensure the nurse aides provided the required assistance with activities of daily living to facility residents. However, she stated she had not noticed Resident #1's teeth were soiled and in need of cleaning until she was questioned by the surveyor. Interview with Clinical Coordinator (CC) #1, on 01/13/2022 at 10:50 AM, revealed he expected staff to provide assistance with activities of daily living, which included oral care to residents in the facility. He also stated staff should provide oral care to Resident #1 every shift and more often if needed and the residents teeth should not have a yellow/brown substance visible to his/her teeth. Interview with the Director of Nursing (DON), on 01/12/2022 at 1:50 PM, revealed staff should provide assistance with activities of daily living to facility residents to ensure their needs were met. He also stated Resident #1's teeth always look like they need brushed and also stated nurse aides should provide oral care to Resident #1, as well as other residents in the facility every shift and as needed. Interview with the Administrator, on 01/13/2022 at 2:40 PM, revealed staff should provide the residents with any assistance needed regarding activities of daily living to ensure the resident's needs were met. He also stated staff should have ensured Resident #1 was properly groomed and his/her teeth were clean.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure a resident received care, consistent with professional standards of practice to prevent a pressure ulcer from developing for one (1) of five (5) sampled residents (Resident #1). Interviews and record reviews revealed staff identified a stage two (2) pressure ulcer to Resident #1's left index finger due to pressure from his/her hand contracture (permanent shortening of joint or muscle causing a deformity) on 10/29/2021. Further review indicated staff determined his/her stage two (2) pressure ulcer was healed on 12/05/2021; however, a red non-blanchable (redness that persists when pressure is applied to the area) area was observed to his/her left middle finger. However, there was no evidence the facility implemented interventions to prevent the further development of pressure ulcers for Resident #1. Observations conducted on 01/11/2022 at 4:15 PM revealed a non-blanchable area which measured 1.5 centimeters (cms) wide and 1.6 cm's long to Resident #1's left middle finger. The findings include: Review of the facility policy titled Skin Ulcers/Injuries dated September 2018 revealed a systemic approach in the prevention and healing of skin ulcers/injuries would be provided. The policy also indicated at least one time a week, residents should receive a head to toe assessment for the identification of any skin conditions and all unusual skin conditions would be noted which included pressure areas (stage one through stage four, unstageable and deep tissue injuries). The policy review also revealed a stage one (1) pressure ulcer was intact skin with non-blanchable redness of a localized area usually over a bony prominence. The policy stated nursing measures to prevent pressure ulcers/injuries would be followed for all residents which included inspect potential sites of breakdown at least once a day, frequently change positions at least every two hours and to use pressure reducing devices as indicated. Review of Resident #1's medical record revealed the facility admitted the resident on 06/24/2019 with diagnoses that included Unspecified Paralytic Syndrome and Contracture of Muscle. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on two (2) staff members for bed mobility and bathing and had functional limitations in range of motion to both sides of his/her upper and lower extremities. According to the MDS Resident #1 was at risk for developing pressure ulcers and had one (1) stage two (2) pressure identified during the assessment period. The MDS also indicated the resident had no speech, was rarely/never understood and rarely/never understood others. The assessment review also revealed he/she was severely cognitively impaired and was unable to be interviewed; therefore, no BIMS score assessment was conducted. Review of Resident #1's nurses notes revealed a stage two (2) pressure ulcer had developed to his/her left index finger on 10/29/2021 was observed to be healed on 12/05/2021. Review of Resident #1's skin integrity assessment dated [DATE] revealed the resident had non-blanchable redness to his/her left middle finger related to pressure from the resident's thumb and index finger. Further review of his/her skin integrity assessment forms revealed on 12/17/2021, 12/24/2021 and again on 12/31/2021, staff continued to observe blanchable redness to his/her left middle finger due to pressure from his/her left index finger. Review of Resident #1's comprehensive care plan last reviewed/revised on 11/23/2021 revealed on 08/31/2021, staff determined the resident had contractures to his/her bilateral upper extremities, and a potential for alterations in skin integrity/pressure ulcer development related to physical limitations, limited mobility, debility and incontinence. Review of interventions implemented included staff would put carrots (a soft carrot shaped device) in the residents hands, assess his/her skin weekly, provide him/her with a pressure reduction mattress to the bed, provide a cushion to his/her chair, observe skin during morning care and alert the nurse of any changes, inform the physician as needed, reposition him/her every two hours and as needed, and assist him/her with activities of daily living as needed and keep his/her call light within reach. Further review of the care plan provided no evidence staff implemented interventions to prevent further pressure ulcers from developing to his/her left hand even though he/she had a history of pressure ulcers due to the resident's contractures. Observations conducted on 01/11/2022 at 4:15 PM, revealed Resident #1's left hand/fingers were contracted. The resident's thumb was also contracted and was applying pressure to his/her left middle finger. Observations also revealed carrots had been placed in both his/her hands; however, the carrot provided no pressure relief to the contractures to the residents fingers to his/her left hand. Further observations on 01/11/2022 of the resident with Licensed Practical Nurse (LPN) #1 revealed a red, slow to blanch area which measured 1.5 centimeters (cm's) wide and 1.6 cm's long was observed to Resident #1's left middle finger. Resident #1 was unable to be interviewed due to his/her cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1, on 01/11/2022 at 4:15 PM, revealed she had identified the red/slow to blanch area to Resident #1's left middle finger a while back. She also acknowledged the resident had a history of pressure ulcers to his/her left index finger and stated I should have put something in place to prevent that red area from becoming a pressure sore but I didn't. Interview with Clinical Coordinator (CC) #1, on 01/13/2022 at 10:50 AM, revealed nurses were expected to implement effective interventions to prevent pressure sores for facility residents when skin impairment concerns were identified. He also stated when staff identified/documented red, slow to blanch areas to Resident #1's left finger secondary to the pressure caused from the residents contractures, staff should have put interventions in place to prevent the development of pressure ulcers for the resident. Interview with the Director of Nursing (DON), on 01/12/2022 at 10:45 AM, revealed staff had implemented the carrots to be placed in Resident #1's hands due to his/her contractures; however, the DON acknowledged the device provided no prevention for pressure ulcer development for the fingers to his/her left hand. He also stated nurses were required to do head to toe skin assessments weekly for facility residents and if skin impairment concerns were identified, interventions should be implemented to prevent the development of pressure ulcers for the residents. According to the DON, when the red/slow to blanch areas were identified to Resident #1's left finger due to his/her contractures, staff should have implemented interventions to prevent pressure ulcers for the resident. Interview with the Administrator, on 01/13/2022 at 2:40 PM, revealed nurses were expected to assess the residents' skin weekly and if abnormal skin conditions were identified which increased the resident's risks for developing pressure ulcers, interventions should be implemented at that time. He also acknowledged staff should have implemented appropriate/effective interventions to Resident #1's left finger, when the red/slow to blanch area was identified in attempts to prevent the development of pressure ulcers for the resident.

Based on observation, interview, record review, policy review, facility's investigation and manufacturer guideline reviews, it was determined the facility failed to ensure two (2) of thirteen (13) sampled residents (Resident #5 and Resident #11) received adequate supervision and assistance to prevent accidents. Review of a facility investigation, dated 09/03/2020 at 1:50 PM, revealed Resident #11 was on a shower bed in the shower room being assisted by State Registered Nursing Assistant (SRNA) #3 and SRNA #8. Both SRNAs were on the same side of the shower bed when they turned the resident toward the shower room wall. The shower bed tipped and the resident fell off the shower bed to the floor sustaining an acute left trochanteric hip fracture and intertrochanteric acute fracture of the left proximal femur. Review of the manufacturer's guidelines for the shower bed revealed exaggerated user movement in any direction may cause the gurney to tip. Do not roll user away from you unless there is a partner caregiver on the other side. Staff interviews and observations revealed the facility was still utilizing the same type shower bed to bathe Resident #11 and were still bathing the resident in the same method (Staff push the shower bed against the wall, both SRNA's stand to one side to the shower bed, and the resident still used the railing to pull self to the side) as when the incident occurred. In addition, review of Resident #5's nurses notes dated 12/30/2020 at 10:45 AM, revealed the resident ingested Hydrocortisone 2.5% Cream (used to treat itching caused by hemorrhoids). The findings include: Review of the facility's policy Falls Prevention Program not dated, revealed the facility goals were to identify all residents who were at high risk for falls and to alter their environment and put interventions in place, to reduce the risk of falls or injuries. The policy also stated interventions would be based on the causative factor of the fall. In addition, the policy stated when the cause of the fall was identified, an intervention would be implemented to eliminate or reduce the possibility of the fall recurring, or attempt to reduce possible injuries. Interview conducted with the Director of Nursing (DON), on 04/29/2021 at 2:43 PM, revealed the facility had no policy related to leaving medicated creams in resident rooms. The DON stated nurses were required to place medicated creams in the treatment cart which was locked, and not left in the resident's room. Review of the one Operation Instructions for Shower Bed TSG700, revealed the operator was to never leave an at-risk user unattended on the bed. Continued reviewed revealed EXAGGERATED USER MOVEMENT IN ANY DIRECTION MAY CAUSE THE GURNEY TO TIP. DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER CAREGIVER ON THE OTHER SIDE. Continued review revealed the guidelines directed the side rail was not to be used as a grab bar. 1. Review of the medical record for Resident #11, revealed the facility admitted the resident on 01/05/2017 with diagnoses which included Paraplegia, Muscle Weakness, Contracture right hand, and Chronic Respiratory Failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required total assistance of two (persons) for bathing. Further review of the MDS revealed the resident had Brief Interview for Mental Status of a fifteen (15) indicating the resident was cognitively intact and was therefore interviewable. Review of the Fall Risk assessment, dated 07/03/2020, revealed Resident #11 required the assistance of two (2) staff with bed mobility and transfers. The MDS also revealed the resident required the total assistance of two (2) staff persons for bed mobility, transfers, dressing, toileting and bathing. Per the assessment, the resident used a hoyer lift with transfers, was not steady and could only stabilize self with staff assistance. Review of a facility investigation, dated 09/03/2020 at 1:50 PM, revealed Resident #11 was being showered in a shower bed by State Registered Nursing Assistant (SRNA) #3 and State Registered Nursing Assistant (SRNA) #8, when the resident fell off the shower bed to the floor sustaining an acute left trochanteric hip fracture and intertrochanteric acute fracture of the left proximal femur. The investigation revealed both SRNA's were on the same side of the shower bed with the other side of the shower bed being against the wall. The incident report revealed after turning the resident towards the wall the shower bed tipped and the resident fell over the side of the shower bed onto the floor. Per the investigation, the resident fell due to being off-center on the shower bed, rolling onto side for care, and being wet. Review of Nurses Notes, dated 09/03/2020 at 1:50 PM, revealed Registered Nurse (RN #5) documented an emergency light sounded from the shower room. Upon entering the shower room, Resident #11 was observed lying on the floor inside a shower stall. The SRNAs in the room reported the resident rolled off the shower bed. Per the nurse's note the resident complained of left hip pain and bruising was noted to the left elbow with a small abrasion. A small abrasion was noted to the left ankle and the right ankle was noted with swelling. Continued review of the nurse's note revealed the resident refused to stay on the floor and staff assisted him/her via hoyer lift to the shower bed to his/her room. Per the note, the Director of Nursing was aware and EMS was notified. Review of the Hospital Record, revealed Resident #11 was admitted to the hospital on 09/03/2020, after a fall and was diagnosed with an acute left trochanteric hip fracture and intertrochanteric acute fracture of the left proximal femur. Per the record the resident required surgical repair (Open Reduction Internal Fixation) of the left hip. The resident was discharged from the hospital and readmitted to the nursing home on 09/11/2020. Review of Resident #11's Care Plan, dated 09/17/2020, revealed the facility addressed the resident's need for assistance with activities of daily living to include bathing. However, the facility had not addressed the use of the shower bed for bathing on the resident's plan of care. In addition, the facility had not addressed safety concerns with the shower bed use after the resident's fall from the shower bed on 09/03/2020. Interview with Resident #11, on 04/28/2021 at 2:55 PM, revealed a few months ago he/she broke his/her hip when he/she fell out of a shower bed. Resident #11 stated a nurse aide had placed his/her feet first in the shower stall and they were washing his/her back. Per the resident, one of the nurse's aides stepped away from the shower bed, the bed tipped and he/she fell off of it breaking his/her hip. The resident stated the railings on the shower bed were not pinned safely. Interview with SRNA #3, on 04/29/2021 at 10:35 AM, revealed on 09/03/2020, she and SRNA #8 were giving Resident #11 a shower using the shower bed. The SRNA stated the resident would use the railing on the wall as a grab bar. Per SRNA #3, when they turned the resident over on his/her side to wash him/her, somehow the bed got pushed away from the wall during the shower. The SRNA stated the shower bed tipped over. The resident went over the bed railing and landed on the floor. The SRNA activated the emergency call light and RN #5 and SRNA #5 responded. Resident #11 insisted on getting up off the shower room floor. Staff placed the resident on a lift pad and the resident was placed back on the shower bed using the mechanical lift. According to the SRNA, the resident was assessed by the nurse and the nurse then contacted Emergency Medical Services (EMS). Interview with SRNA #5, on 04/29/2021 at 4:12 PM, revealed she was not present in the shower room when Resident #11 fell , but responded to the call light. The SRNA stated when she entered the room she observed Resident #11 laying on the shower stall floor between the wall and the shower bed, crying, and demanded staff to get him/her up off the floor. Per the SRNA, she assisted SRNA #3, SRNA #8 and RN #5 with transferring Resident #11 to the shower bed with the Hoyer lift and then back into the resident's bed. Interview with RN #5, on 05/01/2021 at 3:19 PM, revealed on 09/03/2020 she heard a thud sound in the shower room and went to the shower room to find out what was going on. When she entered, Resident #11 was lying on the shower room floor, crying with his/her back to the wall facing the shower bed. The resident stated the bed was not secure and the pins in the bed, which locked the side rails, were missing. Per the RN, Resident #11 insisted staff get him/her off of the floor. The RN stated she, SRNA #3, SRNA #8, and SRNA #5 used a hoyer lift to place Resident #11 onto the shower bed, and then transferred the resident back to his/her room. RN #5 stated she did a skin assessment on Resident #11 after the incident and noted bruising to left elbow with a small abrasion; small abrasion to right ankle and swelling to left knee with bruising. RN #5 stated she thought the pins which locked the side rails in place were missing but did not report this to anyone and did not examine the shower bed on the day of the incident. RN #5 stated SRNA's would leave the pins out sometimes and just take plastic bags and tie the shower bed. The RN stated the metal pins would slide up and down freely. The RN stated if staff lost a pin they would tie the bed with plastic bag until maintenance could replace the pins. The RN stated she had not actually seen staff do this but had heard it had been done. The RN stated SRNA #3 told her that she had stepped away and that's when resident #11 slipped over the side rails falling onto the floor. Per the RN, she contacted EMS and Resident #11 was transferred to the local hospital. Observation on 04/30/2021 at 11:30 AM, of the shower bed Resident #11 fell from on 09/03/2020, revealed the bed was in the education room and no longer being used. Observation of two (2) staff bathing a resident on 04/30/2021 at 2:30 PM, revealed the shower bed Resident #11 had fallen from was not being used. Observation of the shower beds being used, revealed latch pins on the shower beds had a safety lock on the bottom to prevent them from coming out. An SRNA was observed to be in the shower on each side of the shower bed. Interview with the Maintenance Director, on 05/03/2021 at 12:07 PM, revealed he inspected shower chairs, gerichairs, and shower beds weekly. The Maintenance Director stated I check wheels, pins, shower beds for cracks, wear or tear or any loose/missing bolts. If bed is found damaged, had missing screws or pins the bed is pulled out of service and I write a note that's it's out of order. Per the Maintenance Director, the shower bed was pulled after Resident #11's fall and it was the same bed type currently being used. The Maintenance Director stated there were straight pins in the bed with nothing preventing them from coming out. He stated the facility had identified the need for a pin with a safety/lock on the bottom to prevent the pins from slipping out. Per the Maintenance Director, latch pins were purchased locally. The Maintenance Director stated he had installed the latch pins (purchased locally not from the manufacturer) and had used a drill to widen the hole so the latch pins would fit. Further interview with the Maintenance Director revealed he did not contact the Manufacturer of the shower bed prior to purchasing and installing the latch pins. Interview with the Manufacturer of the shower bed, on 05/03/2021 at 2:08 PM, revealed drilling holes in the shower bed to replace the pins would void the warranty on the bed. Review of Maintenance Records for September 2020, October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, and April 2021, revealed weekly checks on shower beds was included with geri-chairs on Preventative Maintenance log reports provided. According to the log, Preventative Maintenance was performed when the equipment was checked. Interview with Director of Nursing (DON), on 04/30/2021 at 2:30 PM, revealed she received a call on Labor Day weekend from RN #5 that Resident #11 had sustained a fall. She was advised that SRNA #3 and SRNA #8 had pushed the shower bed against the wall due to Resident #11's preference as the resident preferred using railings to pull herself over. While SRNA #3 and SRNA #8 was washing the resident; SRNA #3 stated she turned around to get the water nozzle and Resident #11 turned over in the shower bed causing the bed to tip over. The DON stated SRNA #3 thought it was because the resident was top heavy. The DON stated the pins were secure and rails were up when she came into look at the bed. The DON stated new shower beds with higher side rails were purchased after Resident 11's fall. However, observation of the shower beds in use on 04/30/2021, revealed the rails were the same height as the shower bed used by the resident on 09/03/2020. The DON was asked if the manufacturer guidelines were reviewed before use of the shower beds or after Resident #11's fall and the DON did not answer the question. Interview with the Administrator, on 04/30/2021 at 2:55 PM, revealed he had been on vacation when Resident #11 fell from the shower bed but was notified by the DON. The Administrator stated he reviewed incident reports and interventions were put in place to prevent further accidents. The Administrator revealed staff identifying the incident were required to report to the nurse immediately and an incident report was to be filled out. The Administrator stated staff were to notify the DON or Administrator. The Administrator stated he, the DON, and the Supervisor would try to determine the root cause of the fall to ensure interventions were put in place to prevent further falls. The Administrator stated the fall was caused by the resident rolling over and causing the stretcher to tip over. The Administrator was asked if the manufacturer guidelines were reviewed before use of the shower beds or after Resident #11's fall and the Administrator did not answer the question. 29219 2. Review of the medical record for Resident #5, revealed the facility admitted the resident on 11/02/2020, with diagnoses which included Alzheimer's Disease, Aphasia, Chronic Kidney Disease, and Gastroesophageal Reflux Disease. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility had assessed Resident #5 to have a Brief Interview for Mental Status ((BIMS) score of ninety-nine (99) which indicated the facility was unable to interview the resident and the resident was assessed to have moderately impaired cognition Review of Resident #5's care plan dated 11/10/2020, revealed the resident displayed impaired decision making skills and had cognitive deficits. The care plan revealed interventions had been developed to administer medications as ordered, and to provide an organized structured environment with consistency in care. Review of the Nurses Notes for Resident #5, dated 12/30/2020 at 10:45 AM, revealed the resident ingested Hydrocortisone 2.5% Cream (used to treat itching caused by hemorrhoids). The nurses notes also revealed the poison control center had been notified and they had advised the only adverse reaction from the hydrocortisone cream would be potential stomach upset and or diarrhea. Review of an Incident Report, dated 12/30/2020 at 10:45 AM, revealed Licensed Practical Nurse (LPN) #3 had been called to Resident #5's room by State Registered Nursing Assistant (SRNA) #9 because the resident had ingested Hydrocortisone 2.5% Cream (used to treat hemorrhoids). The incident report revealed no cream was observed in the resident's mouth and only a small amount was observed on the resident's lips. The incident report revealed both the resident's physician and spouse were notified of the incident. The incident report further revealed LPN #3 had notified poison control center and had been advised the only adverse reaction from the resident ingesting the Hydrocortisone 2.5% Cream would be an upset stomach and or diarrhea. The incident report also revealed the resident had grabbed the open tube which was within his/her reach and put it into his/her mouth. The incident was witnessed by SRNA #9. The incident report revealed the facility had determined the root cause of the incident was the resident was confused and grabbed the open tube of Hydrocortisone 2.5% Cream (used to treat hemorrhoids) which had been within the resident's reach. Observation of Resident #5, on 04/29/2021 at 10:00 AM, revealed the resident was up in a wheelchair in front of the nurses station propelling himself/herself. Attempted to notify SRNA #9, on 04/30/2021 at 11:13 AM, and on 05/01/2021 at 9:00 AM. Both attempts were unsuccessful. The SRNA was no longer employed by the facility. Interviews with SRNA #3, on 04/29/2021 at 10:29 AM, SRNA #4 on 04/29/21 at 10:40 AM, and SRNA #9 on 04/29/2021 at 12:40 PM, revealed they were not allowed to apply Hydrocortisone 2.5% Cream (used to treat hemorrhoids) and the nurses kept it locked on the treatment cart. Interview conducted with LPN #3, on 04/29/2021 at 11:32 AM, revealed she was responsible for Resident #5 on 12/30/2021, when the resident ingested the Hydrocortisone 2.5% Cream (used to treat hemorrhoids). LPN #3 stated she was called to Resident #5's room by SRNA #9, who was no longer employed by the facility. The LPN stated the cream was on the heater next to the window and she was unsure how it got there. The LPN stated the resident had a little bit of the cream on his/her lips. The LPN stated she had called the poison control center and was told to just monitor the resident for an upset stomach and or diarrhea. The LPN stated Resident #5 had not developed any upset stomach or changes in his/her bowel patterns. The LPN stated medicated creams were not supposed to be left out and in reach of a resident, but were supposed to be kept in the treatment cart locked in the treatment room. The LPN stated she had attended inservices regarding medications and treatments. The LPN stated she did not know how this had happened and it should not have happened. Interviews conducted with LPN #2, on 04/29/2021 at 12:15 PM, and Registered Nurse (RN) #2 on 04/29/2021 at 12:30 PM, revealed nurses were required to apply Hydrocortisone 2.5% Cream (used to treat hemorrhoids) and were required to keep the cream locked in the treatment cart and not within reach of residents. Interview conducted with the DON, on 04/29/2021 at 2:43 PM, revealed she made rounds daily and as part of her rounds she monitored to ensure no medicated creams had been left out and in reach of residents. The DON stated she had not identified any concerns prior to and after the incident with Resident #5. The DON stated nurses were required to place medicated creams in the treatment cart which was locked, and not left in the resident's room where they could be a danger if ingested by a resident.

Based on interview, record review and policy review, the facility failed to ensure an allegation of verbal abuse was reported to state agencies (State Survey Agency and Adult Protective Services) for one (1) of thirteen (13) sampled residents (Resident #12). Resident #12 reported to Registered Nurse (RN) #3 that a nurse aide (State Registered Nurse Aide #9) was rude, hateful to him/her and that he/she did not want the nurse aide to care for him/her. RN #3 moved SRNA #9 to another hallway to work but failed to report the allegation to administrative staff. During an investigation of an allegation of abuse toward another resident (Resident #9) by same SRNA (SRNA #9), the facility became aware of the allegation from Resident #12; however, the facility failed to report the allegation to the required state agencies. The findings include: Review of the Abuse, Neglect, Misappropriation and Exploitation Policy revised January, 2018 revealed All allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing and/or the Administrator of the facility. The Director of Nursing, Administrator or Designee shall report allegations to appropriate state and federal agencies, including law enforcement, as required. 1. When an incident or suspected incident of resident abuse or neglect is reported, the Administrator or Director of Nursing will appoint a representative to investigate the incident. 2. A thorough investigation shall be completed. 3. Results of the investigation may be documented in an Investigative Summary report format or on a Resident Abuse Investigation Report Form. Review of a Facility Investigation, 09/03/2020, revealed Resident #9 reported to SRNA #2, on 03/13/2021, that SRNA #9 was rough with her during care. SRNA #2 reported the allegation to Licensed Practical Nurse (LPN) #1 and the LPN escorted SRNA #9 from the building. The LPN assessed the resident to have no injuries and notified the DON who notified the Administrator. The facility suspended SRNA #9 (who was an agency employee). Per the investigation, the facility did not substantiate abuse. However, further review of the investigation revealed the facility relayed to the staffing agency that they no longer wanted SRNA #9 sent to the facility to work and she has not worked at the facility since 03/13/2021. Further review of the investigation revealed no documentation of other allegations of abuse against SRNA #9 discovered during the investigation. During an interview with SRNA #7, on 04/29/2021 at 1:40 PM, about the incident with Resident #9, the SRNA stated she and SRNA #6 were in the community shower room giving a resident a shower. SRNA #9 was assisting Resident #12 in the restroom and the SRNA was bickering with Resident #12. Per SRNA #7, Resident #12 was asking SRNA #9 why are you being so hateful? Did something happen to you today? The SRNA said SRNA #9 stated she was the one being hateful. The SRNA stated immediately after Resident #12 finished using the restroom, SRNA #6 took Resident #12 out to the nurses station. SRNA #7 stated Resident #12 reported to RN #3 that she did not want that that aide (SRNA #9) to be his/her aide. RN #3 moved SRNA #9 to another hall at that time. The SRNA #7 stated this incident happened before the allegation with Resident #9 and it was reported to RN #3 but she could not remember the date. Review of Resident #12's closed medical record revealed the facility admitted the resident on 09/11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/04/2021, revealed the resident required total assistance of two or more persons physical assist for toilet use. Review of Resident #12's Care Plan, dated 03/29/2021, revealed Resident #12 would be assisted with transfer and mobility every shift, staff were to encourage participation from resident as able, encourage resident to be as independent as able, assist as needed every shift, and check for incontinence/toilet at least every 2 hours and as needed. Staff were also to provide peri-care after each incontinent episode. Phone Interview with Resident #12, on 04/29/2021 at 9:44 AM, revealed he/she could not remember well due to previously having a stroke and aneurysm but he/she remembered telling a nurse that an aide was rude to him/her. Per the resident, he/she told the aide he/she didn't have to take her mouth, but stated the resident could not remember the aide's name. The resident stated the nurse told him/her she would take care of it and stated he/she did not see the aide anymore. Resident #12 was discharged home on 04/08/2021 at 11:00 AM. Interview with SRNA #6, on 04/30/2021 at 11:45 AM, revealed she and SRNA #7 were in the shower room giving a resident a shower (date unknown) and SRNA #9 was in the restroom with Resident #12. Resident #12 started yelling at SRNA #9 saying I'm not being hateful you are the one that's being hateful. SRNA #9 replied No you are the one being hateful. SRNA #6 stated when Resident #12 finished in the rest room that she took Resident #12 out of the restroom and told RN #3 of the incident. Interview with RN #3, on 04/30/2021 at 11:58 AM, revealed that Resident #12 told her that SRNA #9 was being rude and that he/she didn't have to take her mouth. The RN stated the resident also told her that he/she did not want the SRNA to provide care for him/her. RN #3 stated she moved SRNA #9 to another hallway to deescalate the situation. The RN stated she did not report the allegation to administrative staff but stated looking back she should have reported the allegation as verbal abuse. The RN #3 stated she could not remember the date of the allegation that was made by Resident #12. The RN stated she was suspended for not following facility policy when the facility investigated another allegation against SRNA #9. Interview with Administrator, on 04/30/2021 at 2:50 PM, revealed the allegation concerning Resident #12 was not reported to Administration when the incident occurred. The Administrator stated the allegation concerning Resident #12 was reported during the abuse investigation reported by Resident #9 against SRNA #9. The Administrator stated the allegation was not reported to the State Agencies. The Administrator stated he thought since the allegation related to Resident #12 came up during the investigation on Resident #9, it was one investigation. However, further review of the abuse allegation investigation on Resident #9 revealed no mention of the allegation reported by Resident #12, staff interviews or an investigation of the allegation reported by Resident #12.

Based on interview, record review, review of facility policy and review of manufacture guidelines for a shower bed, the facility failed to revise the Comprehensive Care Plan for one (1) of thirteen (13) residents (Resident #11) after an accident involving a shower bed. Review of a facility investigation revealed Resident #11 was on a shower bed in the shower room being assisted by State Registered Nursing Assistant (SRNA) #3 and SRNA #8. Both SRNAs were on the same side of the shower bed when the resident turned toward the shower room wall. The shower bed tipped and the resident fell off the shower bed to the floor sustaining an acute left trochanteric [CONDITION(S)] and intertrochanteric acute fracture of the left proximal femur. Review of the manufacturer's guidelines for the shower bed revealed exaggerated user movement in any direction may cause the gurney to tip. Do not roll user away from you unless there is a partner caregiver on the other side. Review of Resident #11's Comprehensive Plan of Care, 09/17/2020, revealed the facility had not revised the care plan related to the use of the shower bed after the incident. Staff interviews revealed facility staff were currently utilizing the same type shower bed that was used when Resident #11 fell . The findings include: Review of the facility policy titled Protocol for Care Planning, not dated, revealed all residents would have a care plan developed by the Interdisciplinary Team (IDT), based on the resident's individual needs, assessments and goals. The policy also stated the resident's care plan would be reviewed/updated on at least a quarterly basis when the MDS (Minimum Data Set) assessments were completed. The policy directed staff to update care plans with changes in conditions, physician orders and on an as needed basis. Review of the one Operation Instructions for Shower Bed TSG700 revealed the operator was to never leave an at-risk user unattended on the bed. Continued reviewed revealed EXAGGERATED USER MOVEMENT IN ANY DIRECTION MAY CAUSE THE GURNEY TO TIP. DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER CAREGIVER ON THE OTHER SIDE. Continued review revealed the guidelines directed the side rail was not to be used as a grab bar. Review of the medical record for Resident #11, revealed the facility admitted the resident on 01/05/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required total assistance of two (persons) for bathing. Further review of the MDS revealed the resident had a Brief Interview for Mental Status score of a fifteen (15) indicating the resident was interviewable. Review of a Facility Investigation dated 09/03/2020 at 1:50 PM revealed Resident #11 was being showered in a shower bed by State Registered Nursing Assistant (SRNA) #3 and State Registered Nursing Assistant (SRNA) #8, when the resident fell off the shower bed to the floor sustaining an acute left trochanteric [CONDITION(S)] and intertrochanteric acute fracture of the left proximal femur. The investigation revealed both SRNAs were on the same side of the shower bed with the other side of the shower bed being against the wall. The incident report revealed after turning the resident towards the wall the shower bed tipped and the resident fell over the side of the shower bed onto the floor. Per the investigation, the resident fell due to being off-center on the shower bed, rolling onto side for care, and being wet. Review of KARDEX (nurse aide care plan) revealed Resident #11 required the assistance of two (2) staff for bathing and staff were to ensure the resident was in the center of the shower bed when giving the resident a shower. The KARDEX contained no date as to when the previous intervention was added. Review of Resident #11's Comprehensive Care Plan, dated 09/17/2020, revealed the facility had addressed Resident #11 needed assistance with activities of daily living to include bathing. The care plan interventions for bathing included the following: The resident would be assisted; encouraged to participate as tolerated; the resident preferred evening showers between 6:00 PM and midnight. However, the care plan did not include directions for staff when using the shower bed or how the shower bed should or should not be utilized. Interview with Resident #11, on 04/28/2021 at 2:55 PM, revealed a few months ago he/she broke his/her hip when he/she fell out of the shower bed. Resident #11 stated he/she preferred the shower bed against the wall with the staff on one side because it makes him/her feel safer. The resident stated he/she liked to hold on to the bars on the wall that also made him/her feel safe. Per the Resident, this was how he/she was currently being bathed. The resident stated he/she thought the reason for his/her fall from the shower bed was due to one of the aides walked away, when she turned over the shower bed railings was not secure, and the brakes were not locked. The resident stated he/she had not been educated or told to not hold onto the bars or to lay in the center of the bed. Interview with SRNA #3, on 04/29/2021 at 10:35 AM, revealed on 09/03/2020, she and SRNA #8 were giving Resident #11 a shower using the shower bed. She stated that Resident #11 liked to have the shower bed pushed all the way to the wall so he/she can use the grab rails on the wall to pull himself/herself over when staff were washing him/her. The SRNA stated they reviewed the KARDEX and learned hands on regarding what the residents liked and did not like. The SRNA stated Resident #11 was very particular about his/her showers and liked for staff to push the shower bed against the wall and both of the aides to be on one side of the bed. Per the SRNA, Resident #11 would attempt to turn self so staff could wash his/her back/bottom area. The SRNA stated the resident would hold onto the wall railing while staff washed his/her back. Interview with SRNA #4, on 04/29/2021 at 1:37 PM, revealed the SRNA cared for Resident #11 at times and utilized the KARDEX for reference when providing care for the resident. The SRNA was aware of the resident's fall and injury. Per the SRNA, the resident prefered staff to roll the shower bed against the wall during showers. The SRNA stated staff stood to one side of the shower bed and the resident would pull against the side rail to pull himself/herself over so staff could wash the resident's back side. SRNA #4 stated the KARDEX and care plan directed that Resident #11 required the assistance of two (2) staff and a hoyer lift for bathing. The SRNA stated since Resident #11's fall, staff were inserviced that Resident #11 and all residents were to stay in the center of the shower bed during showers. Interview with Director of Nursing (DON), on 04/30/2021 at 2:30 PM, revealed she received a call on Labor Day weekend from RN #5 that Resident #11 had sustained a fall. She was advised that SRNA #3 and SRNA #8 had pushed the shower bed against the wall per Resident #11's preference as the resident preferred using railings to pull himself/herself over. The DON stated the facility process for resident care plans was that the care plan was developed utilizing the resident's MDS by the MDS nurse. The DON stated any change in condition, new orders, etc. should be added by the unit nurses. Per the DON, during morning meetings, attended by the interdisciplinary team, the team reviews all incident reports, orders, KARDEX's and care plans to ensure care plans were updated/revised as needed. The DON could not say why Resident #11's care plan had not been updated after Resident #11's fall from the shower chair. The DON stated falling from the shower bed caused serious harm to the resident. Observation of a resident bath on 04/30/2021 at 2:30 PM, revealed two (2) staff were bathing the resident utilizing a shower bed. The shower bed utilized by staff on 04/30/21, revealed latch pins were in place and a safety lock was on the bottom to prevent them from coming out. A staff member was observed on each side of the bed.

Based on interview and record review, it was determined the facility failed to prevent the possible spread of COVID-19. Per an administrative interview, the facility utilized the protocol, COVID-19 Employee Screening at Change of Shift, for screening staff prior to the staff member entering the resident care area. However, a review of the COVID-19 Employee Screening at Change of Shift forms and staff interviews revealed staff entered the building without taking/recording their body temperature on 06/26/2020, 07/05/2020, and 07/06/2020. The findings include: Interview with the Facility Administrator on 07/09/2020 at 2:53 PM revealed the facility did not have a specific policy regarding screening and taking temperatures of staff but the facility did have a protocol. According to the Administrator, the facility utilized the COVID -19 Employee Screening at Change of Shift form and staff were required to take their temperature when arriving at work and before entering resident care areas of the facility. The Administrator stated staff were then required to document the temperature on the form and if any signs of COVID-19 illness were present, staff were to notify Management for further guidance. A review of Page 5 of the facility protocol titled, Protocol: COVID-19, with a revision date of 04/01/2020, revealed under the section titled, Monitor and Manage Healthcare Personnel, staff were to be screened at the entrance to the facility prior to the start of their shift. Each staff member was to be questioned about symptoms, travel, and exposure, and temperature taken. Further review revealed if an employee presented with a fever of 100.4 they would be sent home and advised to contact their healthcare provider. A review of twenty (20) undated COVID-19 Change of Shift Screening of Employees Forms revealed eight entries with no evidence of an employee's temperature being documented prior to the employee starting work. A review of a COVID-19 Change of Shift Screening of Employees Form dated 06/26/2020 revealed Physician #1 entered the building and there was no evidence of a temperature documented on the form. Interview with Physician #1 on 07/09/2020 at 9:53 AM revealed the physician had entered the building on 06/26/2020 but could not recall why his temperature was not documented. According to the physician, he may have taken his own temperature and not documented the temperature on the log or may have been in the building earlier and had his temperature taken. Further interview revealed sometimes when the physician enters the building staff will do the screening and the temperature and sometimes when no staff are at the door, the physician will take his own temperature and write it on the log. Further interview with the physician revealed he had not provided care for any COVID positive patients and he was assigned to this facility only to prevent possible spread from facility to facility. An interview with State Registered Nurse Aide (SRNA) #1 on 07/08/2020 at 3:01 PM revealed that when staff arrive at work and there is no one to take temperatures, staff take their own temperatures but only if a thermometer is available. According to the SRNA, the thermometer is often not available and staff have to try to find it. Interview with SRNA #2 on 07/08/2020 at 4:38 PM revealed he recalled a day when a thermometer was not available to take temperatures but he could not recall the date. Per the SRNA, since a thermometer was not available, staff signed in and went to the nurses' station, and took their temperatures before starting work. SRNA #2 stated that often there were no probe covers available for the ear thermometer to utilize to take temperatures. Further interview revealed the facility did have a no-touch forehead thermometer that was often not at the screening location when the SRNA came to work. Interview with SRNA #4 on 07/09/2020 at 9:02 AM revealed when staff come to work they screen themselves, take their own temperature, and document it on the log prior to starting work. Further interview revealed a thermometer is often not available and staff have to contact the nurse on the radio to find the thermometer. Interview with SRNA #5 on 07/08/2020 at 4:13 PM revealed a thermometer was not available when she arrived at work for her shift starting at 6:00 PM on 07/06/2020. The SRNA stated she was not able to take her temperature until she went to the nurses' station and found a thermometer. Further interview revealed the SRNA did not go back and document the temperature on the log. The SRNA stated she did not have a fever or any signs and symptoms of COVID-19 on 07/06/2020. Interview with SRNA #6 on 07/08/2020 at 4:55 PM revealed she was required to take her temperature and document on the log when she arrived at work. The SRNA stated she was not aware why her temperature was not documented. According to the SRNA, a thermometer is not always available at the screening location. The SRNA stated staff entered the building and went to the nurses' station to find the thermometer in order to take their temperature. Interview with SRNA #7 on 07/08/2020 at 5:04 PM revealed the SRNA had come to work on 07/05/2020 at 6:00 PM and a thermometer was not available in the screening area. Per the SRNA, she started work and took her temperature later in the shift but did not document the temperature. According to the SRNA, staff takes the thermometer from the screening location to use to take residents' temperatures on the floor and does not put the thermometer back at the screening location. Interview with Licensed Practical Nurse (LPN) #1 on 07/09/2020 at 12:54 PM revealed staff check their own temperatures before they start work. According to the LPN, she had not had any problems with the facility thermometers being available in the screening area. The LPN stated she may have forgotten to document her temperature on the log and this might be why there was no temperature recorded by her name. Interview with the Director of Nursing (DON)/Infection Preventionist on 07/09/2020 at 2:26 PM revealed she had not identified any concerns with the staff screening procedure or with staff failing to obtain/document their temperatures prior to starting work. According to the DON, all staff were trained to check their temperatures and to self-screen prior to starting work. The DON stated if there were any concerns, a walkie-talkie radio was available at the screening area to reach someone for assistance. Interview with the facility Administrator on 07/09/2020 at 2:53 PM revealed staff were required to check their temperatures and self-screen prior to starting work. The Administrator stated staff were to sign acknowledging they were free of symptoms and document their temperature before starting work and providing care. According to the Administrator, he checked the COVID-19 change of shift screening of employees form daily but did not check every form. The Administrator stated he was not aware that employees were having problems finding a thermometer to take their temperatures or starting work without taking their temperature.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food under sanitary conditions for eighty-three (83) residents that received food trays on 09/10/19. Observation on 09/10/19 revealed opened/undated food being stored in the refrigerator. In addition, two (2) men were observed to enter the kitchen and walk behind the steam table, while food was being served, with uncovered hair. The findings include: Review of the facility's policy titled Leftovers, undated, revealed leftover food would be labeled and dated. Review of the facility's policy titled Personnel Standards and Behavior, undated, revealed hairnets, covering all of the hair, must be worn at all times when on duty in the kitchen. Observation during the initial tour of the kitchen on 09/10/19 at 9:40 AM, revealed an unlabeled, undated large clear container of red liquid and a forty (40) -ounce opened, undated package of sliced ham in the refrigerator. In addition, on 09/10/19 at 11:40 AM, during the noon tray line, two (2) men were observed to enter the kitchen and walk behind the steam table while trays were being served with no hairnets or beard covers. The Dietary Manager (DM) and the Registered Dietitian (RD) escorted the men out of the kitchen and they immediately left the facility and were unable to be interviewed. Interview conducted with the DM and RD on 09/10/19 at 11:45 AM, revealed the men had been contracted to repair the deep fryer and were not aware that they were required to wear hairnets. The DM stated the repairmen left the facility after she told them they needed to wear hairnets. The DM and RD stated the repairmen had not been educated regarding hairnets because they usually came at night when food was not being served. Continued interview with the DM and RD revealed every food item in the refrigerator should be labeled and dated as to the contents and when the food item had been opened. The DM stated she monitored the refrigerators and freezers every morning when she arrived for work to ensure all food items had been labeled and dated; however, she had not identified that the red liquid and ham were not labeled.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-seven (27) sampled residents was adequately supervised to prevent accidents. The facility's policy required that the name and picture of all residents who were at risk for elopement be placed in an Elopement Risk Book at each nurses' station. The facility assessed Resident #42 to be at elopement risk; however, the resident's picture and name were not included in the facility's Elopement Risk Books. The findings include: Review of the facility policy, Elopement Risk Assessment & Monitoring, not dated, revealed an Elopement Risk assessment would be completed for each resident, and if the resident was determined to be at risk for elopement their name and photograph would be placed in an Elopement Risk Book that was kept at each nurses' station. Review of Resident #42's medical record revealed the facility admitted the resident on 12/16/09 with [DIAGNOSES REDACTED]. Observation of Resident #42 on 09/11/19 at 10:35 AM revealed the resident was sitting at the nurses' station. The resident's speech was unclear. Further observation revealed the resident was wearing a Secure Care Bracelet to the right ankle. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. According to the Staff Assessment for Mental Status, the resident was normally able to recall the location of his/her own room, staff names and faces, and that he/she was in a nursing facility/hospital. Further review of the MDS revealed the resident had a wander/elopement alarm. Review of Resident #42's Elopement Risk assessment dated [DATE] revealed the facility assessed the resident to be at risk for elopement related to [DIAGNOSES REDACTED]. However, review of the facility's Elopement Risk Books located on Unit 100, Unit 200, and the Front Office revealed that Resident #42's name and picture were not in the books. Interview on 09/29/19 at 11:19 AM with State Registered Nursing Assistants (SRNAs) #3 and #4 revealed they knew who was at risk for elopement by looking at the resident's care plan. Both SRNAs agreed that if they were not sure what the resident looked like they would refer to the Elopement Risk Book, which had the pictures of the resident. Interview with the Director of Social Services on 09/12/19 at 4:23 PM revealed that anyone that had a bracelet should be in the elopement book. He stated it was his responsibility to update the Elopement Risk Book, but he was not notified of the responsibility until yesterday. Interview on 09/12/19 at 6:50 PM with the Director of Nursing (DON) revealed every resident was assessed for the risk of elopement upon admission, quarterly, and as needed. She stated it could be problematic if a resident was assessed to be at risk for elopement and a photo was not placed in the Elopement Risk Book.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent infections for one (1) of twenty-seven (27) sampled residents (Resident #24) and one unsampled resident (Resident #89). During observation of incontinence care on 09/11/19 for Resident #24, the State Registered Nursing Assistant (SRNA) took a package of opened wipes from the roommate's overbed table, placed then onto the bed of Resident #24, and proceeded to use the wipes for Resident #24's incontinence care. In addition, observation of meal service on 09/12/19 revealed staff failed to perform hand hygiene prior to serving Resident #89's meal. The findings include: 1. Review of the facility policy titled, Infection Prevention & Control Program, no development or revision date, revealed, The facility shall maintain an Infection Prevention & Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Interview with the Director of Nursing (DON) revealed the facility did not have a policy related to residents sharing personal supplies; however, the DON stated residents should not share incontinence wipes. Record review for Resident #24 revealed the facility admitted the resident on 03/21/19 with [DIAGNOSES REDACTED]. Review of Resident #24's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7), indicating severe cognitive impairment. Further review of the resident's MDS revealed the resident was always incontinent of bowel and bladder. Observation on 09/11/19 at 10:01 AM revealed State Registered Nursing Assistant (SRNA) #4 was providing incontinence care for Resident #24. The SRNA raised the resident's bed, looked around the room, and then stated, (Resident #21), I don't see your wipes, I'll have to go get some. The SRNA then walked across the room to the roommate's overbed table, picked up a package of opened wipes, placed the wipes on Resident #24's bed, and provided incontinence care. Interview with SRNA #4 on 09/11/19 at 2:02 PM revealed the facility had just provided an infection control training a few weeks ago, and the SRNA stated she was aware that staff were not allowed to share resident supplies like briefs, wipes, or personal hygiene products with other residents. When asked about the wipes used for Resident #24's incontinence care, SRNA #4 stated, I'm sorry. I guess I got nervous. Interview on 09/12/19 at 2:24 PM with the Clinical Coordinator revealed her expectations were that residents' belongings were not to be used on other residents. She stated that she made rounds at least every two (2) hours and had not identified a concern with incontinence care. Interview with the Infection Control Nurse on 09/12/19 and the DON on 09/12/19 at 6:57 PM confirmed that a package of wipes from the overbed table of one resident should not have been placed on the bed of another resident, and stated that would be a break in infection control. 2. Review of the facility policy titled Serving Meal Trays, undated, revealed staff were required to practice hand hygiene when serving meal trays. Observation of staff serving meal trays on 09/10/19 at 11:59 AM revealed SRNA #4 approached the meal tray cart, touched the inside of her left ear with her left hand, and proceeded to take a meal tray for Resident #89, without sanitizing her hands. SRNA #4 attempted to serve the tray to the resident; however, Resident #89 was out of the facility and the tray was returned to the kitchen for disposal. Interview with SRNA #4 on 09/12/19 at 10:25 AM, revealed she did not remember touching her ear and retrieving a tray from the meal cart to serve without sanitizing her hands. SRNA #4 further stated she had been instructed to always sanitize her hands prior to touching any meal trays for serving; however, the SRNA stated it was just an automatic reflex and she forgot to sanitize her hands after touching her ear. Interview with the Director of Nursing (DON) on 09/12/19 at 6:55 PM, revealed staff were instructed to sanitize their hands immediately prior to touching a resident's meal tray for serving, and should not touch anything after sanitizing their hands prior to touching the meal tray.

Based on interview, record review, and review of the facility discharge policy it was determined the facility failed to protect discharge rights of one (1) of three (3) sampled residents (Resident #1). There was no evidence of required physician documentation for the discharge in the medical record. Resident #1 was issued a discharge notice due to the facility alleging the discharge was necessary for Resident #1's welfare and that the resident's needs could not be met in the facility. Review of the record revealed no evidence of the required physician documentation. The findings include: A review of the facility policy titled Transfer and Discharge Rights, with a revision date of (MONTH) (YEAR), revealed a resident would not be transferred or discharged unless the discharge was necessary to meet the resident's welfare or if the health of individuals in the facility had been endangered. Further review of the policy revealed the resident's physician would document in the medical record the reason for the discharge. Interview with Resident #1 on 08/28/19 at 11:35 AM revealed the resident had been issued a discharge notice due to verbal abuse and smoking. The resident stated the discharge had been appealed and the resident was awaiting a hearing. Further interview with the resident revealed the resident was concerned about the discharge because the resident did not have anywhere to go or anyone available to provide care if the resident had to leave the facility. A review of the medical record for Resident #1 revealed the facility admitted the resident on 01/05/17 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) Assessment completed for Resident #1 dated 07/05/19 revealed the resident was assessed to not be ambulatory, require extensive assistance of two (2) staff persons to transfer, had limited range of motion to upper and lower extremities, was always incontinent of bowel, and required the use of a catheter to empty the bladder. A review of a discharge notice issued to Resident #1 and the resident's family dated 07/25/19 revealed the resident was to be discharged due to the discharge being necessary for the resident's welfare and the resident's needs could not be met in the facility. The notice stated the resident failed to comply with medication guidelines and was self-medicating. Further review of the notice revealed the resident was being discharged because the health of individuals in the facility was otherwise endangered. According to the notice the resident was to be discharged to a private residence. A review of the medical record for Resident #1 revealed no evidence of the required physician documentation related to the discharge of Resident #1. An interview with the Physician for Resident #1 on 08/28/19 at 2:00 PM, revealed the physician had been contacted by the facility regarding the discharge; however, the physician had not documented or been asked to document required discharge documentation in the medical record. According to the physician he could provide care for the resident at the facility and had no concerns with Resident #1 self-medicating with marijuana; however, he was concerned with the resident not following the facility smoking policy because the resident could harm him/herself or others. According to the Physician, he had no concerns with the resident staying at the facility or the resident being discharged to a safe place, but was not aware of where the resident could go except to another facility because the resident was unable to care for him/herself. An interview with the facility Administrator on 08/29/19 at 11:30 AM revealed the Administrator had issued Resident #1 a discharge notice on 07/24/19 due to the resident's behavior of using and testing positive for marijuana, and not following the facility smoking policy by hiding cigarettes and lighters in his/her room or on his/her person. The Administrator stated he was not aware the physician was required to document the reasoning for the discharge in the resident's medical record. Further interview revealed Resident #1's discharge was on hold due to the resident's appeal and the resident's family was not able to take care of the resident.

Based on interview, record review, and policy review, it was determined the facility failed to ensure an allegation of abuse for one (1) of three (3) sampled residents was thoroughly investigated, and failed to ensure residents were protected during the abuse investigation. On 05/20/19 at 1:30 AM, Resident #3 was in a motorized wheelchair at the doorway of another resident's room requesting State Registered Nurse Aide (SRNA) #1 to assist him/her to bed. Resident #3 reported that he/she put his/her hand in the door attempting to keep it open so he/she could talk to the SRNA, and the SRNA slammed the door. After the incident occurred, Resident #3 reported to staff (SRNA #2 and LPN #1) that SRNA #1 had slammed his/her hand in the door. LPN #2 called the Director of Nursing (DON) and reported the allegation of abuse. Although the DON advised LPN #2 to send SRNA #1 home, the facility failed to initiate an investigation of the abuse allegation and failed to investigate the allegation of abuse prior to permitting SRNA #1 to return to work. SRNA #1 returned to work providing direct resident care on 05/20/19 at 6:00 PM. Furthermore, the facility did not initiate an investigation of the allegation until Resident #3 reported the allegation to the State Survey Agency (a Surveyor) who was present in the facility on 05/23/19, three (3) days after the resident made the abuse allegation. The facility's failure to ensure allegations of abuse were investigated and failure to protect residents from the alleged perpetrator during abuse investigations has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/24/19 and was determined to exist on 05/20/19 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610). The facility was notified of the Immediate Jeopardy on 05/24/19. An acceptable Allegation of Compliance was received on 06/07/19, which alleged removal of the Immediate Jeopardy on 05/29/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 05/29/19, prior to exit on 06/10/19, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, revised (MONTH) (YEAR), Abuse, Neglect, Misappropriation and Exploitation Policy, revealed Protection: When an allegation is made regarding abuse, neglect, exploitation, or misappropriation the employee shall immediately be suspended pending investigation. The Administrator, Director of Nursing, or designee will ensure the employee immediately leaves the facility. When an employee witnesses an incident of suspected abuse, neglect, exploitation or misappropriation the employee shall ensure safety first prior to reporting to appropriate personnel. The policy also addressed Abuse and/or Resident Neglect Investigation 1) When an incident or suspected incident of resident abuse or neglect is reported, the Administrator or Director of Nursing will appoint a representative to investigate the incident. 2) A thorough investigation shall be completed. 3) Results of the investigation may be documented in an Investigative Summary report format or on a Resident Abuse Investigation Report Form .6) At the conclusion of the investigation, and no later than 5 working days of the incident, the facility will report the results of the investigation and if the alleged violation is verified, the corrective action taken to the State Survey Agency in accordance with the state law. Review of Resident #3's medical record revealed the facility admitted the resident on 01/05/17 and the resident's [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and interviewable. Further review of the MDS revealed the resident was totally dependent and needed the assistance of two (2) staff members for transfers. On 05/23/19 at 4:15 PM, Resident #3 requested to speak with the Surveyor and reported that a couple of nights ago, SRNA #1 had slammed his/her hand in a door. The resident stated he/she had requested assistance with getting into bed approximately 45 minutes prior to the incident, and was checking with the SRNA to see how much longer it would be before she could assist the resident. Resident #3 stated he/she was at the doorway of another resident's room and had placed his/her hand in the cracked doorway to keep the SRNA from shutting the door so he/she could speak to the SRN[NAME] The resident stated the SRNA saw his/her hand in the door and slammed the door on his/her hand. The resident stated he/she had reported the incident that night to other staff working and again to the Administrator the next afternoon. The resident stated SRNA #1 was back to work the next evening. Resident #3 stated he/she sustained a bruise to the top of his/her hand due to the incident. After Resident #3's interview, the allegation was reported to the Administrator immediately on 05/23/19 at 4:30 PM and an interview was conducted with the Administrator. The Administrator stated he was aware of the incident involving Resident #3. According to the Administrator, SRNA #1 was giving another resident a bath when Resident #3 attempted to enter the room and the resident's hand was caught in the door. The Administrator denied that Resident #3 reported an allegation on 05/20/19 and stated he did not talk to the resident until 05/22/19, when the resident came and told him that he/she was trying to crack the door open and SRNA #1 shut the door. The Administrator stated the resident did not say the SRNA did it on purpose. However, further interview with Resident #3 on 05/24/19 at 2:45 PM revealed the resident did not state the incident was not purposeful. Additional interview with the Administrator revealed a thorough abuse investigation was not completed prior to SRNA #1 returning to work and providing direct care to residents on the evening of 05/20/19. When asked to provide an investigation of the incident, an incident report and a statement from SRNA #1 was provided on 05/23/19. The next day, 05/24/19, a statement from the DON and Registered Nurse (RN) Unit Manager were provided with a brief summary. Review of the summary provided by the facility on 05/24/19, dated 05/20/19, stated that the Unit Manager (RN #2) had interviewed residents on 05/20/19 (related to another resident to resident investigation) and had interviewed Resident #3 who had denied anyone hitting or hurting her. However, interview with Resident #3 on 05/24/19 at 2:45 PM revealed he/she did not remember talking to RN #2. The resident stated facility staff had been in his/her room that morning (05/24/19) trying to mess me up. Per the resident, he/she liked to stay up late and slept late in the day. The resident stated that morning (05/24/29) staff had come to his/her room trying to get him/her to say the incident with his/her hand being slammed in the door was not intentional. The resident stated he/she did not know if it was intentional or not and had never told staff it was not intentional. Continued review of the facility's summary received on 05/24/19 revealed the Administrator had interviewed the resident on 05/20/19; however, interview with the Administrator on 05/23/19 at 4:30 PM and again on 05/24/19 at 4:50 PM revealed he did not talk to the resident until 05/22/19. In addition, the summary indicated the Administrator talked to SRNA #1 over the phone and the SRNA stated that the resident shut the door on his/her own hand and that the SRNA provided a statement. However, interview with SRNA #1 on 05/23/19 at 4:55 PM revealed she was asked to write a statement about the incident with Resident #3. The SRNA stated the Administrator did not ask her what happened, only asked her to write the statement. Further review of the facility's summary revealed that SRNA #1 was allowed to work Monday night (05/20/19) because no negative findings were found during the resident interviews completed by RN #2, the DON, Administrator, or LPN #1; and because the incident report and the SRNA's statement confirmed the original story that there was no allegation of abuse originally reported. However, the summary contained no interviews with other staff working on the night shift (05/19/19 into 05/20/19). Interview with the Administrator on 05/23/19 on 4:30 PM revealed interviews with staff working on 05/20/19 were not completed on 05/20/19. Review of the Nurse's Notes dated 05/20/19 at 1:30 AM revealed .Upon putting res in bed, res stated (R) hand got slammed in door. DON made aware. Review of the incident report dated 05/20/19 at 1:30 AM revealed the resident had a crescent-shaped bruise to the top of the right hand. Interview with RN #2 on 05/24/19 at 5:14 PM revealed she had conducted resident interviews on 05/20/19 per request and had asked residents questions about physical abuse. The RN stated she asked residents if anyone had hit or hurt them. According to RN #2, she woke Resident #3 and questioned the resident mid-day on 05/20/19. Per the RN, she did not ask Resident #3 about the incident where he/she alleged that his/her hand was slammed in a door because she was not aware of the incident at the time of the interviews. Interview with the DON on 05/23/19 at 4:40 PM revealed nursing staff contacted her at approximately 2:00 AM on 05/20/19 because Resident #3 was upset and demanding to go to bed. The DON said the resident barged into another resident's room where SRNA #1 was giving a bath. The SRNA turned to close the door, but did not see the resident's hand and the door hit the resident's hand. Per the DON, the staff stated it looked like the resident's hand/fingers were going to bruise. The DON stated she told staff to send the SRNA home until an investigation could be completed. In a second interview with the DON on 05/24/19 at 4:37 PM, the DON stated she did not feel it was anything but an accident, but told staff to send the SRNA home as a precaution until someone could talk to the resident. The DON stated she did not do an investigation, nor speak to the resident, and documented on the incident report regarding an interview that the Administrator had with the resident (05/20/19). The interview was documented on the incident report as occurring on 05/20/19. However, interview with the Administrator on 05/23/19 at 4:30 PM revealed he did not speak with the resident about the incident until 05/22/19. Interview with the Administrator on 05/23/19 at 4:30 PM and on 05/24/19 at 4:50 PM revealed he coordinated all abuse investigations. The Administrator stated he learned about the incident with Resident #3 on Monday, 05/20/19, during the facility's morning meeting. Per the Administrator, the incident report revealed the resident's hand was caught in a door. The Administrator stated he called the SRNA and asked her to come in and write a statement as to what happened. He stated that SRNA #1 was permitted to return to work on the evening of 05/20/19 because no one alleged that this incident was possible abuse or that it was done on purpose. The Administrator stated Resident #3 came to him on 05/22/19 and they discussed the incident. During further interview, the Administrator stated he asked the resident if the SRNA did this on purpose and the resident said, No. The Administrator stated if staff had reported that the SRNA had purposely slammed the resident's hand in the door, we would be doing what we are doing now (referring to conducting an abuse investigation). Per the Administrator, the facility started an alleged abuse investigation on 05/23/19, after the State Agency Surveyor reported Resident #3's allegation. Further interview with the Administrator revealed the facility had not interviewed the other staff who worked on 05/20/19 until after the SSA reported the allegation on 05/23/19. Review of the facility's five (5) day investigation/Final Report received on 05/28/19 related to the alleged abuse reported by Resident #3 revealed the facility did not believe abuse occurred. Continued review of the summary revealed the resident's recollection of the events had changed multiple times. However, per the summary, the resident told the Medical Director on 05/27/19, that he/she had put his/her hand in a door to stop it from shutting, which resulted in the resident's hand getting caught in the door. Interview with Resident #3 on 05/22/19 and 05/23/19 revealed the same recollection of the incident from the resident. Further review of the five (5) day report revealed the Social Worker and an LPN (LPN #6) interviewed the resident and the resident told them he/she did not think the SRNA shut the door on purpose. Interview with the Social Worker and LPN #6 on 05/24/19 at 10:47 AM and review of their statement revealed they interviewed Resident #3 on 05/24/19, regarding the incident on 05/20/19. Per their statement, the resident stated, I can't say for sure if it was on purpose, but I don't think that she did it on purpose. Further interview with the Social Worker revealed that abuse investigations were a group effort, but she was not aware of the allegation with Resident #3 until 05/23/19. Interview with Resident #3 on 05/24/19 at 2:45 PM revealed he/she liked to sleep late and staff had come to his/her room that morning trying to mess me up. The resident stated he/she had told staff he/she did not know if the SRNA had intentionally hurt his/her hand and had never told staff that it was not intentional. The resident stated, I reported my hand was hurt when the nurse aide slammed the door. **The facility alleged the following actions removed Immediate Jeopardy on 05/29/19: 1. Resident #3 was fully assessed by a nurse on 05/20/19 and a small crescent-shaped bruise to the top of the resident's right hand was identified. The physician was notified on 05/20/19. SRNA #1 was suspended pending investigation. 2. A Department Head meeting was conducted on 05/24/19 to review the information detailed in the Immediate Jeopardy Notification and develop a plan for IJ abatement. Those in attendance included: Administrator, Director of Nursing (DON), Consultant Staff, Clinical Coordinators, Minimum Data Set (MDS) Coordinators, and Staff Development Coordinator. On 05/24/19, the Medical Director was notified of the IJ notification and the plan for abatement. 3. On 05/27/19, all staff members, including those that had worked with Nurse Aide #1, were interviewed by the DON, Clinical Coordinators, Staff Development Coordinator, or MDS Coordinators to determine if there were any other identified concerns/incidents with notification to appropriate state agencies as indicated and no concerns noted. 4. On 05/27/19 and 05/28/19, all interviewable residents (residents with a BIMS score of 8) were interviewed by Clinical Coordinators, Staff Development Coordinator, or the Social Worker to determine any other concerns/incidents with notification to appropriate state agencies as indicated; no concerns noted. 5. On 05/27/19 and 05/28/19, the DON, Clinical Coordinators, Staff Development Coordinator, or MDS Coordinators assessed residents that were non-interviewable for any bruises or injuries of unknown origin; no concerns noted. 6. On 05/25/19, Consultants began reviewing all allegations of abuse/neglect that had not already been investigated by the State Agency with the Administrator to ensure the facility's Policy was being followed, specifically, notification of allegation to state agencies (i.e., Office of Inspector General (OIG who is also the SSA, and APS), immediate removal of the alleged perpetrator from the facility until investigation was completed, and a thorough completion of an investigation with necessary corrective action as indicated. 7. On 05/24/19, the Administrator and DON were in-serviced by the Consultant Staff regarding conducting thorough investigations, including reporting allegations timely to appropriate state agencies (i.e., OIG and APS), and immediate removal of the alleged perpetrator from the facility pending investigation. The in-service also included interviewing staff that had worked with the alleged perpetrator, interviewing residents that had care provided by the alleged perpetrator, and if possible, documenting the conclusion of the investigation, and any necessary corrective action. 8. On 05/24/19, the DON, Clinical Coordinators, Staff Development Coordinator, MDS Coordinators, Housekeeping Supervisor, and Dietary Manager began staff education regarding the Abuse Policy & Procedure and will continue until all employees have been re-educated prior to their next scheduled shift. Staff will not be permitted to work until they have received in-servicing. After in-servicing of staff on the Abuse Policy & Procedure, a Post-Test was conducted by the DON, Clinical Coordinators, Staff Development Coordinator, and MDS Coordinators with staff to ensure retention and understanding. No staff were allowed to work until passing the post-test. 9. Consultant staff will review all abuse allegations to ensure the Abuse Policy & Procedure has been followed. Specifically, the review will consist of ensuring the allegation was reported to state agencies in a timely manner; alleged perpetrator was suspended until completion of an investigation; and the investigation was thorough and complete with the conclusion, when possible, and corrective actions taken. These reviews will be conducted by the Administrative Consultant or Nurse Consultant on all abuse/neglect investigations weekly for one month, and then monthly for one quarter. 10. Random post-testing will continue with five (5) staff members on a daily basis for two (2) weeks, and then five (5) staff members weekly for one month. The post-tests will be administered by the DON, Clinical Coordinators, Staff Development Coordinator, or consultants. Results of the post-tests will be provided to the weekly QA Committee by the Staff Development Coordinator. 11. A QA meeting was conducted on 05/27/19 to review the status of the in-service education, review monitoring and audit results, and progress of plan. Those in attendance included: Administrator, DON, Clinical Coordinators, MDS Coordinators, Staff Development Coordinator, Consultant Staff, and Medical Director. A QA Meeting will be held at a minimum of weekly until substantial compliance is achieved and then monthly thereafter. ***The State Survey Agency determined the following actions removed Immediate Jeopardy on 05/29/19, as alleged by the facility: 1. Record review and observations on 06/07/19 revealed SRNA #1 was suspended from the facility on 05/24/19, after the facility was notified of the Immediate Jeopardy. 2. A review of facility documentation revealed the facility conducted a department head meeting on 05/24/19 to develop a plan for abatement of the immediate Jeopardy. Interviews on 06/09-10/19 with the Administrator, the DON, and the Nurse Consultant confirmed they met on 05/24/19 to develop a plan for abatement of the Immediate Jeopardy. 3. Review of the facility's documentation revealed the facility interviewed all staff regarding SRNA #1's care of residents on 05/27/19 and no other concerns were identified. Interviews with SRNAs #8, #9, #10, #11, and #12 and LPNs #5 and #7 on 06/08/19 and 06/09/19 revealed the facility had interviewed the staff regarding SRNA #1's care of residents. 4. Review of facility documentation revealed the facility interviewed all residents with a BIMS score of 8 or higher on 05/27-28/19 and no other concerns were identified. Observations conducted during a tour of the facility on 06/07/19 of Residents #3, #4, and #5, and unsampled Residents K, L, M, N, and O and interviews with the residents revealed no concerns that residents were being abused or were not being protected from abuse. 5. Review of facility documentation revealed the facility conducted skin assessments for residents who were not interviewable on 05/27-28/19, and no concerns were identified. Interviews with the Clinical Coordinators for the 100 Hall and 200 Hall, and the MDS Coordinator on 06/08/19 revealed they conducted skin assessments on all residents with a BIMS score that was less than eight (8) and no concerns were identified. 6. Review of facility documentation and interviews with the Nurse Consultant on 06/10/19 revealed the consultant reviewed seven (7) allegations since 05/23/19 and found no further instances where resident abuse allegations were not investigated or reported. 7. A review of an in-service roster and an interview with the Nurse Consultant on 06/10/19 revealed she conducted an in-service for the Administrator and the DON regarding the facility's abuse policy and conducting thorough investigations on 05/24/19. Interviews with the DON and the Administrator on 06/10/19 confirmed that the Nurse Consultant educated them regarding the facility's abuse policy and conducting a thorough investigation and they completed a post-test. 8. Review of an in-service roster and post-tests and interviews with SRNAs #8, #9, #10, #11, and #12 and LPNs #5 and #7 on 06/08/19 and 06/09/19 revealed the staff had been retrained regarding the facility's policy and procedure for abuse and had completed a post-test. Interviews with the Consultant on 06/10/19 confirmed that all staff had been educated and no one would be permitted to work until the education was completed and the staff member passed the post-test. 9. A review of the facility's investigations completed since 05/29/19 revealed three (3) allegations involving Resident #3. No concerns were identified regarding reporting or investigating the allegations. Review of facility documentation and interviews with Consultants on 06/10/19 revealed they had also reviewed the allegations to ensure they were reported to state agencies (i.e., OIG and APS) in a timely manner, the alleged perpetrator was suspended until completion of an investigation, and the investigation was thorough and complete. 10. A review of the facility's Quality Assurance documentation revealed the facility had been conducting five (5) random post-tests for facility staff weekly. Interviews with the DON, Administrator, and the Consultant on 06/10/19 revealed the facility was randomly testing staff regarding their knowledge of the facility's abuse policy. Interviews with the Clinical Coordinators for the 100 Hall and 200 Hall, and the MDS Coordinator on 06/08-09/19 revealed they had been conducting random post-tests as a part of the facility's ongoing Quality Assurance. 11. Review of facility documentation revealed a Quality Assurance meeting was conducted on 05/27/19 to review the ongoing progress of the monitoring of the A[NAME]. Interviews conducted on 06/09-10/19 with the Clinical Coordinators, MDS Coordinator, DON, Administrator, Medical Director, and the Nurse Consultant revealed they had attended the QA meetings weekly to monitor the progress of the A[NAME].