Every finding on record at Crittenden County Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure the physician acknowledged the pharmacist's recommendation for a resident's monthly medication regime review for one of five sampled residents (Resident (R) 43) reviewed for unnecessary medications.The findings include: On 03/05/2026 at 10:12 AM, the Director of Nursing (DON) stated the facility did not have a policy that specified the timeframe in which a physician must respond to the consultant pharmacist's monthly medication regime review. Review of R43's Resident Face Sheet revealed the facility the resident on 08/27/2020 with diagnoses which included heart failure, hyperkalemia, and gastro-esophageal reflux disease without esophagitis. Review of R43's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2026, revealed the resident had a Brief Interview for Mental Status score of 14 out of 15, which indicated the resident had intact cognition. Review of R43's Consultation Report for the timeframe 11/01/2025-11/30/2025, 12/01/2025-12/31/2025, and 01/01/2026-01/31/2026, revealed no evidence the physician and/or designee acknowledged the recommendations of the Pharmacist regarding the resident's medication regime review. During an interview on 03/05/2026 at 8:29 AM, the DON stated residents' consultation reports of the pharmacist's medication regime review recommendations were still located in the physician books with documents awaiting a signature. The DON reported she spoke with the physician, who stated they believed the reports had been taken home and not yet returned to the facility. During an interview on 03/05/2026 at 11:58 AM, Nurse Practitioner (NP) 10 stated she currently had a stack of consultant reports from the Pharmacist on her desk that had not yet been returned to the facility. NP10 stated she could not recall whether she had reviewed or signed the consultation reports of the resident's medication regimen review for R43. NP10 stated facility staff placed the recommendations (consultation reports) in a folder, which she typically picked up and took with her to review. NP10 stated their office had experienced staffing shortages, and she was behind on completing the reviews. During a follow-up interview on 03/05/2026 at 9:51 AM, the DON stated she was unaware the consultation reports had not been signed. The DON stated the documents slipped through the cracks But she expected the pharmacy documents to be completed within 30 days. During an interview on 03/05/2026 at 10:05 AM, the Administrator stated she expected the pharmacist's consultation reports were signed when the providers reviewed the folders.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff wore a gown when they provided care to residents on enhanced barrier precautions (EBP) for one (Resident 42) of one sampled residents reviewed for tube feeding, one of (Resident 33) of one sampled residents reviewed for pressure ulcer/injury, and one (Resident 42) of five sampled residents reviewed for infection control.The findings include: A facility policy titled, Enhanced Barrier Precautions, reviewed 01/2025, specified, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. The policy specified, 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens g. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, etc. h. Wound care: any skin opening requiring a dressing (may exclude shorter-lasting wounds, such as skin breaks or skin tear covered with a Band-aid or similar dressing). 1. Review of R42's Resident Face Sheet revealed the facility admitted the resident on 05/09/2025 with diagnoses which included diagnoses of encounter for attention to gastrostomy and dysphagia. Review of R42's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/23/2026, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident had a feeding tube. Review of R42's Physician Order Report revealed an order dated 02/17/2026 for enhanced barrier precautions (targeted gown and gloves use) during high-contact resident care activities every shift. During a concurrent interview and medication administration observation on 03/04/2026 at 11:54 AM, Registered Nurse (RN) 3 prepared and administered medications to R42 by way of the resident's gastrostomy tube. RN3 washed her hands and applied gloves but did not put on a gown. Observation revealed there was signage above the resident's bed that indicated EBP were required. RN3 stated she was uncertain if R42 still required EBP. During an interview on 03/05/2026 at 10:21 AM, the Director of Nursing (DON) stated all residents who had a wound and any artificially inserted device such as a feeding tube were to be on EBP. The DON stated she would expect staff to put on a gown and gloves when they provide care to any resident on EBP. 2. Review of R12's Resident Face Sheet revealed the facility admitted the resident on 09/22/2025 with diagnoses which included diagnoses of encounter of orthopedic aftercare following surgical amputation and a non-pressure chronic ulcer of other part of right foot with necrosis to the bone. Review of R12's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident had diabetic foot ulcer(s) and surgical wound(s). Review of R12's Care Plan included a problem statement dated 09/22/2025, that indicated the resident required enhanced barrier precautions (EBP) related to a diabetic ulcer of the bilateral feet and a recent amputation of the second toe on the left foot. Interventions specified enhanced barrier precautions (targeted gown and glove use) during high contact resident care activities (initiated 09/22/2025). Review of R12's Physician Order Report revealed an order dated 12/12/2025, for enhanced barrier precautions (targeted gown and glove use) during high contact resident care activities every shift. During wound care observation on 03/04/2026 at 4:47 PM, the Director of Nursing (DON) did not wear a gown when she performed wound care on R12's surgical wound. During an interview on 03/05/2026 at 10:21 AM, the DON stated residents who had wounds and any artificially inserted device such as catheters, feedings tubes, and intravenous lines were to be placed on enhanced barrier precautions. The DON stated she only wore gloves during the treatment, and it slipped her mind that the resident was on EBP and that she should have applied a gown during wound care for the resident. During an interview on 03/05/2026 at 12:46 PM, the Administrator stated she expected all staff to wear a gown and gloves during the provision of resident wound care. 3. Review of R33's Resident Face Sheet revealed the facility admitted the resident on 07/26/2018 with a diagnosis of cerebral infarction. Review of R33's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/2026, revealed the resident had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. Review of R33's Care Plan included a problem statement initiated 04/29/2025, that indicated the resident required enhanced barrier precautions (EBP) related to a stage 4 pressure injury to their sacrum. During wound care observation on 03/04/2026 at 2:26 PM, Licensed Practical Nurse (LPN) 7 did not wear a gown when he performed wound care on Resident 33. During an interview on 03/04/2026 at 5:18 PM, LPN7 stated he was not aware of EBP or what personal protective equipment was required. LPN7 confirmed he did not wear a gown when provided R33's wound care. During an interview on 03/05/2026 at 7:58 AM, LPN9 stated she was aware of EBP and when wound care was performed, staff were expected to wear a gown and gloves. During an interview on 03/05/2026 at 10:21 AM, the DON stated all residents who had a wound and any artificially inserted device such as a feeding tube were to be on EBP. The DON stated she would expect staff to put on a gown and gloves when they provide care to any resident on EBP. During an interview on 03/05/2026 at 12:46 PM, the Administrator stated she expected all staff to wear a gown and gloves during the provision of resident wound care.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food items in the walk-in freezer were not labeled or dated. Staff failed to completely cover their hair while in the kitchen. Staff failed to cover prepared food on the warming table. A cold food was not at the proper temperature for serving. These failures had the potential to affect all 61 of the facility's residents who consumed food from the kitchen. The findings include: 1. Review of the facility's policy titled, Storage Procedures, dated 08/2023, revealed, Food shall be properly stored to preserve flavor, nutritive value, and appearance. Per policy review, all foods in the freezer were to be wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. In addition, they were to be labeled and dated with use by dates clearly marked. Observation of the walk-in freezer, at 12:11 PM on 02/04/2025, revealed five chicken patties, six hamburger steaks, five chicken fritters, and five chicken cordon bleu were not labeled or dated. Interview with the Dietary Manager, on 02/04/2025 at 12:15 PM, revealed that all left over foods should be labeled and dated before putting into the freezer. She further stated that it could cause residents to become sick if they eat something outdated. 2. Review of the facility's policy titled, Food Temperature Records/Controls, dated 08/2023, revealed, Cold foods should be 41 degrees or less when the temperature is taken in the kitchen, at the time of service. Additionally, per the policy, prepared perishables such as salads, puddings, milk, etc., should be stored in a refrigerator and covered until use. At 11:32 AM on 02/04/2025, observation revealed that various foods were prepared for lunch and were placed on the hot bar, waiting to be plated. Observation of this area revealed that all the foods were covered with plastic, with the exception of two large containers of chicken pot pie. This food remained uncovered until 11:37 AM when [NAME] 2 entered the kitchen and covered the containers of chicken pot pie. After covering the food, [NAME] 2 was observed to take the temperatures of all foods that were to be served for the lunch, with the exception of the mayonnaise-based coleslaw that was being served as a substitute for the scheduled salad. After [NAME] 2 indicated that the foods were ready to be served, the survey team asked [NAME] 2 to check the temperature of the coleslaw. This food, which was supposed to be served cold, measured 57 degrees. After surveyor intervention, the coleslaw was not used for lunch and a substitute was served. Interview with [NAME] 2, on 02/04/2025 at 12:07 PM, revealed she forgot to cover the chicken pot pie before she left the kitchen for a few minutes She added that she had prepared the coleslaw that morning and left the filled containers out, next to the stove, because she was going to serve the coleslaw for lunch. Interview with the Dietary Manager, on 02/04/2025 at 12:15 PM, revealed that food should be covered before leaving it on the warmer. She states that germs or flies could get into the food and cause sickness for the residents. She stated she did not know why the cook left the food uncovered before leaving the kitchen. 3. Review of the facility's policy titled, Dietary Dress Code, dated 08/23, revealed, All dietary service employees will wear clean and safe apparel. Per policy review, hair nets or hair restraints were to be worn, and hair should be completely under the hair restraint with no bangs protruding from any side of one's scalp. An initial tour of the kitchen on 02/04/2025 at 11:31 AM, with the Dietary Manager revealed that food was being prepared for the lunch meal. Observation at this time revealed that the Dietary Manager's hair was pulled back in a bun. The Dietary Manager was wearing a hairnet; however, it only covered the bun portion of her hair and the rest of her hair was uncovered. Additional observation of the Dietary Manager on 02/05/2025 at 1:30 PM, again revealed that only the back portion of her hair was covered. Interview with the Dietary Manager, on 02/05/2025 at 1:30 PM, revealed that she had trouble with her hair covering not staying on/slipping back and the facility was trying to order a different type of hairnet that would hopefully cover all her hair. In interview with the Administrator of the facility on 02/07/2025 at 5:15 PM, she stated her expectation was that all of her staff followed policies. She stated that, If staff do not wear their hairnets properly, hairs could get in the food and that would not be good. The Administrator added that she expected the dietary staff to label and date all leftover foods in the freezer, saying that it could make the residents ill if they ate things that were freezer burnt or outdated. Further interview with the Administrator revealed that she expected foods to be covered and be served at the correct temperature. She stated serving coleslaw at a temperature of 57 degrees was not acceptable and could cause residents to become sick.

Based on observation, interview, record review, and facility policy review, the facility failed to implement multiple interventions on the comprehensive person-centered care plan for one (Resident (R) 37) of two sampled residents reviewed for wound care. Interventions regarding treatment orders, infection control measures, and odor control were not implemented in accordance with the resident's care plan. The findings include: Review of the facility policy, Resident Assessment Comprehensive Care Plans, updated 05/24/2022, revealed the facility must implement a comprehensive person-centered care plan for each resident. The intent stated, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Review of the facility policy, Comprehensive Care Plans, effective 11/28/2017, revealed, the services provided or arranged by the facility, as outlined by the comprehensive care plan must meet professional standards of quality. Under procedure, it revealed, professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Review of the face sheet revealed R37 was admitted to the facility on [DATE] with diagnoses which included fistula of intestine-enterocolic and colocutaneous, and a colostomy related to megacolon/abdominal surgery. A. Review of the Comprehensive Care Plan, dated 05/09/2023, with a problem of ostomy related to megacolon and abdominal surgery, revealed ostomy care will be managed appropriately. Approaches included enhanced barrier precautions (EBP) during high contact resident care activities. On 02/06/2025 at 2:40 PM, observation revealed Licensed Practical Nurse (LPN) 1 failed to wear a gown (part of the facility's required EBP) while providing wound care (a high contact resident care activity) to R37. (Refer to F880). During an interview with LPN1 on 02/07/2025 at 2:33 PM, he stated he did not take the time to put on a gown (as an EBP) prior to providing care; however, he continued, he should have taken the time. LPN1 stated the Comprehensive Care Plan was used to tell everyone how to care for all the resident sand confirmed he was not following the care plan as written. B. Review of the Comprehensive Care Plan, dated 09/04/2024, revealed the resident had a problem of an open area to the left buttock, which was verified by a medical doctor as a chronic fistula wound. Review of the Comprehensive Care Plan, dated 05/23/2024, revealed the resident also had a problem of an open area to the right buttock. Both care plan problems included a goal to heal skin and prevent infection. Care Plan approaches to meet these goals included for staff to deliver prescribed treatment. Review of the physician-prescribed treatment orders, dated 02/01/2025, revealed an order for wound care, with a start date of 01/18/2025, which included cleansing the buttock wounds with Dial soap and water, as well as the application of Neosporin ointment (triple antibiotic ointment) 3.5 milligrams, to the wounds. An observation on 02/06/2025 at 2:40 PM during wound care revealed LPN1 failed to follow the care plan by delivering the prescribed treatment. LPN1 cleansed the resident's wounds with Dakin's solution, instead of with Dial soap and water. Further observation of the treatment revealed LPN1 failed to apply Neosporin ointment, and instead applied a topical lotion (Dermacil). During an interview with LPN1 on 02/07/2025 at 2:33 PM, he acknowledged that he had not provided the prescribed treatment in accordance with the care plan. (Refer to F684.) C. Review of the Comprehensive Care Plan, dated 07/19/2023, revealed the resident has odor problems related to the ostomy and fistula. The goal was for the resident's room to have a pleasant odor. An approach was that the resident would have a scented plug-in in his room at his request. An observation on 02/06/2025 at 2:40 PM, revealed LPN1 preparing to provide ostomy and wound care During this observation, it was noted that the resident did not have a scented plug-in in his room to control odors. A strong foul odor was noted in the resident's room and could also be smelled throughout his hall and the surrounding halls. An interview with Housekeeper 1 on 02/06/2025 at 10:38 AM revealed that housekeeping staff cleaned R37's room each day while the resident went out to smoke, and no one had mentioned that they needed to obtain a plug in to control the odor in the resident's room. During an interview with the Director of Nursing (DON) on 02/07/2024 at 2:58 PM, she stated she expected all staff to follow the Comprehensive Care Plans as written. She stated the care plans should be person centered, developed, and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to provide non-pressure wound care in accordance with the resident's care plan and physician orders for one (Resident (R) 37) of two sampled residents reviewed for wounds. The findings include: Review of R37's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included a fistula of intestine-enterocolic and colocutaneous, and a colostomy related to megacolon/abdominal surgery. Review of the Comprehensive Care Plan, dated 09/04/2024, revealed the resident had a problem of an open area to the left buttock which was verified by the medical doctor as a chronic fistula wound. Review of the Comprehensive Care Plan, dated 05/23/2024, also revealed the resident had an open area to the right buttock. The care plan goal for each wound was to heal skin and prevent infection. An approach to meet this goal was for staff to deliver prescribed treatment. Review of physician orders, dated 02/01/2025, revealed an order for wound care, with a start date of 01/18/2025. The prescribed treatment included: Neosporin ointment (triple antibiotic ointment) 3.5 milligrams, 1 application topical. Special Instructions: buttock wounds, cleanse with Dial soap and water, pat dry. Apply Neosporin to wounds along with lidocaine, cover with gauze island dressing every shift and as needed if soiled or dislodged. During an observation of ostomy care and skin assessment on 02/06/2025 at 2:40 PM, Licensed Practical Nurse (LPN) 1 failed to follow physician orders. LPN1 was observed to cleanse the resident's buttock wounds with Dakin's solution, rather than Dial soap and water as ordered. LPN1 then applied a topical skin lotion (Dermacil), instead of using the physician-ordered triple antibiotic ointment (Neosporin). Interview with LPN1, on 02/07/2025 at 2:33 PM, revealed he was the charge nurse on the floor and that wound care was completed by whichever nurse was working the floor that day. Interview with LPN1 revealed that he was aware that the physician's order called for cleansing the wound with Dial soap and water. However, he failed to follow the order because he thought the Dakin's solution would do a good job of cleaning the wound. Further interview revealed he was also aware that the orders called for applying Neosporin; however, he thought by using the skin lotion, it would help the resident's excoriated skin at the fistula/ostomy sites. LPN1 confirmed he was not following the physician orders as written. An interview with the Director of Nursing (DON) on 02/07/2025 at 2:58 PM revealed her expectation was that nursing staff follow physician orders and provide quality of care per professional standards. During an interview with the Administrator, on 02/07/2025 at 3:30 PM, she stated she expected all nursing staff to follow physician orders as written and to provide quality of care with wound care.

Based on observation, interview, record review, and policy review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for one (Resident (R) 37) of two residents reviewed for wound care. Facility staff failed to perform hand hygiene as indicated before, during, and after ostomy and wound care. Staff failed to use enhanced barrier precautions (EBP) designed to reduce transmission of multidrug-resistant organisms even though the resident had wounds that required EBP. Treatment supplies, including scissors and ointment, were handled in a manner that did not prevent the spread of infection. In addition, hand hygiene was not monitored by supervisory staff as planned as part of the facility's surveillance/monitoring activities. The findings included: Review of the facility policy, Infection Control Program, reviewed 01/2025 revealed the purposed of the infection control program in the nursing facility was to minimize the effects of infections on residents and employees, and to educate the staff. The Infection Control Manual, reviewed 01/2025, revealed staff will wash hands before donning gloves for resident care, during care when soiled, between glove changes, and after care is completed before leaving the resident's room. Review of the policy for Isolation-Categories of Transmission-Based Precautions, updated 10/2023 and reviewed 01/2025, revealed EBP for close contact resident care included the use of gloves, a gown, and eye protection if there was a risk of splashing fluids. Review of the policy, Monitoring Infection Control Practices, dated 01/2022, revealed the facility's infection control preventionist will conduct routine monitoring and surveillance to determine compliance with infection control policies and practices. Review of the face sheet revealed R37 was admitted to the facility on [DATE] with diagnoses which included a fistula of intestine-enterocolic and colocutaneous, and a colostomy related to megacolon/abdominal surgery. Observation on 02/06/2025 at 10:09 AM revealed a sign on the right side of the door to R37's room, which noted the resident was on EBP. During an observation of ostomy care and a wound assessment for R37 on 02/06/2025 at 2:40 PM, Licensed Practical Nurse (LPN) 1 failed to use all required EBP during ostomy care to the lower abdomen and wound care to the left and right buttock. LPN1 did not don a gown prior to completing ostomy and wound care. In addition, LPN1 failed to wash his hands prior to, during, and after ostomy care and wound care. Each time he removed his gloves, he did not wash his hands prior to donning another pair of gloves. During ostomy care, he took a topical lotion for external use and used a dirty gloved finger to place the lotion on and around an excoriated area of the resident's fistula/ostomy. LPN1 further took a pair of scissors from his pocket using his dirty gloves and cut out an area of the ostomy wafer before securing it around the fistula and the ostomy. He then used his dirty scissors to cut another wafer to fit on the left side of the abdomen. After placing the new ostomy bags to the abdomen, LPN1 was requested to assess the wounds to the resident's buttocks. Without washing his hands after ostomy care, LPN1 proceeded to don another pair of gloves. He began care of the wounds on the resident's bilateral buttocks by cleansing the areas with Dakin's solution, which was not the ordered care (Refer to F684.) However, LPN1 did not clean all of the dried stool from the wounds before he applied a treatment and dressing. After the procedures were completed, LPN 1 removed his gloves, placed them in a red bag along with the contaminated ostomy bags, and left the open red bag, which had a foul odor at the resident's bedside. LPN1 proceeded to leave the room and go to the nurses' station. He did not perform hand hygiene before he then went into the medication room. During an interview with LPN1 on 02/07/2025 at 2:33 PM, he stated he had a bad habit of not washing his hands. LPN1 added that, There are bad outcomes, from not performing hand hygiene as he could pass bad pathogens back and forth between residents. LPN1 also stated he was aware that R37 was on enhanced barriers due to his ostomy and wounds; however, he confirmed that he failed to put on a gown prior to providing care. He also stated he should have tied up the red bagged contaminated dressing and removed it from the resident's room. During an interview with the Infection Control (IC) Nurse on 02/06/2024 at 3:10 PM, she stated she received her IC certificate in 05/2024. She stated she had not watched LPN1 do wound care. The IC Nurse added that she is supposed to do hand hygiene evaluations two times a week. However, the IC Nurse continued, she could not currently watch all staff for hand hygiene practices as she is working the floor. She stated she expected LPN1, and all staff, to use good hand hygiene practices, use the required personal protective equipment including gowns, and remove all contaminated trash from the room after care, per infection control policy. An interview with the Director of Nursing (DON), on 02/07/2025 at 2:58 PM, revealed her expectation was for nursing staff to follow the infection control policy as written, use good hand hygiene, and use the personal protective equipment provided. During an interview with the Administrator on 02/07/2025 at 3:30 PM, she stated she expected all nursing staff to follow facility policies regarding good infection control practices, which included hand hygiene and removing soiled ostomy bags and dressing. She stated she expected staff to remove the soiled items from the room and replace a clean bag to the trash can.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for two (2) of three (3) sampled residents (Resident #40 and Resident #41). Although it was not within the Scope of Practice for a Licensed Practical Nurse to declare death or sign the Provisional Report of Death or Death Certificate, review of Resident #40's Provisional Report of Death, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 completed and signed the form. Additionally, review of Resident #41's Provisional Report of Death, dated [DATE], revealed LPN #3 completed and signed the form. The findings include: Review of a facility policy titled, Provisional Report of Death Form, undated, revealed the facility was responsible for completing and ensuring completion of Sections A, B, and C. Part B was to be completed by the local Registrar, Coroner, or Hospice nurse and it was acceptable for a facility nurse to complete and sign section B as well. Review of an Advisory Opinion Statement from the Kentucky Board of Nursing, approved ,d+[DATE] and revised ,d+[DATE], revealed per KRS 314.021(2), all individuals licensed under provisions of this chapter should be responsible and accountable for making decisions based upon the individual's educational preparation and experience in nursing and should practice nursing with reasonable skill and safety. It further stated it was not within the Scope of Practice for a Licensed Practical Nurse to declare death or sign the Provisional Report of Death or Death Certificate. 1. Review of Resident #40's Face Sheet revealed the facility admitted the resident on [DATE] and the resident expired on [DATE] with diagnoses to include: wedge compression fracture of unspecified thoracic vertebrae, fracture of right shoulder, girdle, part unspecified, sequela prior fracture and unspecified dementia without behavioral disturbance. Review of Resident #40's Provisional Report of Death, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 completed and signed the form. 2. Review of Resident #41's Face Sheet revealed the facility admitted the resident on [DATE] and the resident expired on [DATE] with diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, and psychotic disturbance. Review of Resident #41's Provisional Report of Death, dated ,d+[DATE]//2021, revealed LPN #3 completed and signed the form. During a telephone interview with LPN #3, on [DATE] at 5:55 PM, she stated she worked at the facility until [DATE] and did not recall if the facility had asked her to sign death certificates. LPN #3 stated she had signed death certificates in the past at the facility but could not remember the last time she signed a death certificate. Further, she stated she did not know the regulation related to LPN's not being able to sign death certificates when she worked at the facility, but she was now aware she was not allowed to sign death certificates as she had been told she was not permitted to do so. During an interview with LPN #2, on [DATE] at 6:30 PM, she stated she had not signed a death report, but had signed as a witness. LPN #2 stated only a Medical Provider, Funeral Home or a Registered Nurse was permitted to sign a death certificate. During an interview with the Director of Nursing (DON), on [DATE] at 2:36 PM, she stated any licensed nurse was permitted to sign a provisional death certificate. The DON stated she expected an LPN to only work within their scope of practice but was unaware an LPN could not sign a death certificate. During an interview with the Administrator, on [DATE] at 3:10 PM, she stated the facility did permit LPNs to sign provisional death certificates and had never had an issue with that before. However, the Administrator stated she did not know if an LPN was qualified to sign a provisional death certificate.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good personal hygiene related to incontinence care for one (1) of forty (40) sampled residents (Resident #17). Observation on 02/20/2024 at 1:20 PM, revealed a strong odor of urine in Resident #17's room, and the resident was noted to be lying in bed with his/her pants and bed linens soiled with a yellow/brown substance. The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs)/Maintain Abilities, dated 03/2023 and reviewed 01/2024, revealed the facility would specify the responsibility to create and sustain an environment that humanizes and individualized each resident's quality of life by ensuring all staff across all shifts and departments understood the principle of quality of life and honor and support those principles for each resident; and that the care and services provided were person-centered and honor and support each resident's preferences, choices, values and beliefs. The facility would provide care and services for: hygiene, elimination and dining. A resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #17's Face Sheet revealed the facility admitted the resident on 01/25/2021 with diagnoses to include: Huntington's disease, Muscle weakness, and Frostbite with tissue necrosis of the left foot. Review of Resident #17's Annual Minimum Data Set (MDS) Assessment, dated 01/17/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of six (6) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #17's Comprehensive Care Plan related to frequent bladder incontinence, dated 12/11/2023, revealed the goal the resident would not exhibit skin breakdown, urinary tract infection, impaired social interaction or lowered self-esteem secondary to incontinence. Interventions included: provide assistance for toileting every two (2) hours and as needed and provide incontinence care after each incontinent episode. Observation on 02/20/2024 at 1:02 PM, revealed a strong odor of urine on the 300 hall. Observation on 02/20/2024 at 1:20 PM, revealed a strong odor of urine in Resident #17's room. Upon further observation, Resident #17 was laying in bed and his/her pants were soiled with a yellow/brown substance. The resident's bed linens were also stained with a yellow/brown substance. Continued observation on 02/20/2024 revealed the State Survey Agency attempted to locate the Certified Nurse Aide (CNA) assigned to Resident #17 and was informed by CNA #1 that she was on lunch break. CNA #1 stated he was not assigned but would help with any resident that needed assistance. CNA #1 and SSA went to Resident #17's room and CNA #1 asked Resident #17 if he could provide care. Resident #17 was laying on the bed, stated he/she did not like showers but did sit up on the side of the bed and with assistance from the CNA, walked to the bathroom. CNA #1 proceeded to clean the resident with a washcloth and dressed him/her with clean clothing. The housekeeper removed the soiled linen from the resident's bed and wiped down the mattress with a spray disinfectant cleaner. CNA #1 then applied clean linen on Resident #17's bed and assisted the resident back to bed. During an interview with Certified Nursing Assistant (CNA) #1, on 02/20/2024 at 1:40 PM, he stated Resident #17 was often resistive to care, aggressive and combative towards staff. CNA #1 stated he was unsure when the resident was last provided incontinence care as he was not assigned to the resident but assigned to another hall. CNA #1 stated the CNA assigned to the 300 hall was on her lunch break. CNA #1 further stated the CNA assigned to Resident #17 probably did not want to get hit so she had left the resident like that if he/she was exhibiting combative behaviors. CNA #1 stated a resident had the right to refuse care and should never be forced to do anything he/she didn't want to do. During an interview with CNA #2 on 02/20/2024 at 2:45 PM, she stated she last checked on Resident #17 around 11:00 AM and he/she had refused care at that time. CNA #2 further stated Resident #17 often refused care and she would notify someone in administration to see what she should do. CNA #2 stated she notified the Activities Director to see if she would try to get the resident to allow care to be provided and the Actives Director told her to just pull the resident's curtain shut and leave him/her alone. CNA #2 stated she did what she was instructed to do. During an interview with Licensed Practical Nurse (LPN) #1, on 02/20/2024 at 2:20 PM, he stated he had last checked on Resident #17 before breakfast. LPN #1 stated he did walk through rounds and if everything looked good, he would just keep going. LPN #1 stated CNA #2 was assigned to Resident #17. He stated CNA #2 should have had another staff member attempt to provide care to the resident and if he/she continued to refuse, the nurse should be notified. However, LPN #1 stated he had not been notified that Resident #17 had refused care today. During an interview with the Activities Director (AD), on 02/22/2024 at 2:40 PM, she stated CNA #2 did come to get her earlier in the day to assist with Resident #17 and she told the CNA to get another staff member to try if the resident was agitated. The AD stated she may have told the CNA to pull the curtain and leave the resident alone because he/she was a tough cookie and wanted to be left alone. However, she stated if the resident was soiled in urine or feces, someone should have provided incontinence care. During an interview with CNA #7, on 02/23/2024 at 1:28 PM, she stated Resident #17 did not like staff touching him/her, but she thought it was because of how those staff members approached the resident. CNA #7 stated if Resident #17 refused care, she would notify the nurse and go back and try again a little later. If the resident continued to refuse care, she would just leave the resident like that because he/she could get combative. During an interview with the Director of Nursing (DON), on 02/23/2024 at 2:36 PM, she stated rounds for toileting and incontinent care should be done at least every two (2) hours and she expected the staff to do that. She stated if incontinence care was not provided timely or every two (2) hours, this could result in a write-up for the staff member assigned. The DON stated Resident #17 refused care a lot, but if he/she refused, staff should notify their supervisor and ask someone else to try. She further stated there had been times the resident would not allow any staff to assist him/her. During an interview with the Administrator, on 02/23/2024 at 3:10 PM, she stated she did not know if rounds should be done within an exact timeframe. The Administrator further stated staff were always on the floor making rounds and she expected them to do their job and provide the residents the care that was needed to prevent urinary tract infections or skin breakdown from occurring.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Observation on 02/22/2024 at 9:00 AM, revealed lancets (a small needle used to puncture the skin of the finger in order to obtain a small drop of blood to test blood sugar) were left unattended on top of a treatment cart on the 500 hallway. The findings include: Review of the facility policy titled, Incidents, dated 11/2019 and reviewed 01/2024, revealed all incidents or accidents occurring on the premises would be investigated and reported to the Administrator and/or the Director of Nursing. Observation on 02/22/2024 at 9:00 AM, 11:05 AM, and 2:25 PM, revealed lancets were sitting in a basket on top of the treatment cart and left unattended on the 500 hallway. During an interview with Licensed Practical Nurse (LPN) #1, on 02/22/2024 at 2:25 PM, he stated he would normally lock the lancets and glucometer supplies inside the cart, but he just had not had time to do so. Observation during this interview revealed LPN #1 immediately took the lancets and locked them inside the Treatment cart. During an interview with Registered Nurse (RN) #1, on 02/22/2024 at 2:00 PM, she stated lancets and glucometer supplies should always be stored inside a locked Treatment cart. During an interview with the Director of Nursing (DON), on 02/23/2024 at 2:26 PM, she stated lancets should not be left on top of a cart because a resident could potentially have access to them and be injured or stuck. During an interview with the Administrator, on 02/23/2024 at 3:10 PM, she stated she expected staff to lock lancets inside the medication cart. The Administrator stated someone could potentially be stuck if the lancets were left on top of the Treatment cart.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) sampled residents (Resident #34). Observation on 02/22/2024 at 11:05 AM, revealed Licensed Practical Nurse (LPN) #1 performed a blood glucose finger stick on Resident #34, then doffed his gloves, and failed to perform hand hygiene prior to exiting the room. The findings include: Review of the facility policy titled, Infection Control Program, reviewed 03/2023, revealed the facility would minimize the effects of infections on residents and employees and educate the staff by having an effective Infection Control Program. Review of Resident #34's Face Sheet revealed the facility admitted the resident on 11/21/2023 with diagnoses to include: Depression, Neuromuscular dysfunction of Bladder, and Type two (2) Diabetes Mellitus with hyperglycemia. Review of Resident #34's Quarterly Minimum Data Set (MDS) Assessment, dated 01/10/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating intact cognition. During an observation on 02/22/2024 at 11:05 AM, Licensed Practical Nurse (LPN) #1 performed a blood glucose finger stick on Resident #34. The LPN then doffed his gloves, but failed to perform hand hygiene and exited Resident #34's room. Further observation revealed LPN #1 sanitized the glucometer with germicidal Sani-Wipes and then proceeded to enter obtained results into the Electronic Medical Record (EMR). During an interview with LPN #1, on 02/22/2024 at 11:10 AM, he stated he should have doffed his gloves, and then washed his hands after providing care to Resident #34 to possibly prevent the spread of infections to other residents. During an interview with the Infection Prevention (IP) Nurse, on 02/23/2024 at 11:00 AM, she stated the facility conducted in-services on handwashing to staff often. She stated all new employees were required to perform an immediate skill check off on handwashing within the first twenty-four (24) hours of beginning work at the facility. During an interview with the Director of Nursing (DON), on 02/23/2024 at 2:36 PM, she stated she expected staff to perform handwashing anytime they doffed their gloves or provided any care to a resident. The DON further stated failure to wash hands after providing care was an Infection control issue. During an interview with the Administrator, on 02/23/2024 at 3:10 PM, she stated she expected staff to always wash their hands before and after resident care.

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to provide means for resident(s) to directly contact caregivers through a communication system which relays the call directly to a staff member or to a centralized staff work area for three (3) of forty (40) sampled residents (Residents #17, #35, and #36). Observation of Resident room [ROOM NUMBER] on 02/20/2024, revealed the call lights for Residents #17 and #36 did not have a push button on the end resulting in the residents not being unable to call for help if needed. Additionally, Resident 17's call light was hanging on the wall and out of reach. The findings include: Review of the facility policy titled, Standards of Nursing Practices, dated 05/2018 and reviewed 01/2024, revealed staff would respond to resident's request for assistance by answering call lights within a reasonable amount of time, within ten (10) minutes. Review of the facility policy titled, Resident Rights, updated 09/2022 and reviewed 01/2024, revealed the facility would ensure the residents had the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. Review of the facility policy titled, Maintenance Services, undated, revealed the facility would provide a safe, sanitary and comfortable environment for residents, staff and the public. The maintenance department was responsible for maintaining the buildings, grounds and equipment in a safe and operable manner. 1. Review of Resident #36's Face Sheet revealed the facility admitted the resident on 08/20/2019 with diagnoses to include: Schizophrenia, unspecified, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #36's Quarterly Minimum Data Set (MDS) Assessment, dated 01/10/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating intact cognition. Observation on 02/20/2024 at 1:20 PM in room [ROOM NUMBER], revealed Resident #36's call light was attached to the bed rail and did not have a push button on the end of it. 2. Review of Resident #17's Face Sheet revealed the facility admitted the resident on 01/25/2021 with diagnoses to include: Huntington's disease, Muscle generalized weakness, and Unsteadiness on feet. Review of Resident #17's Annual Minimum Data Set (MDS) Assessment, dated 01/17/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15) indicating severe cognitive impairment. Observation on 02/20/2024 at 1:20 PM in room [ROOM NUMBER], revealed Resident #17's call light was hanging on the wall by the head of the bed and did not have a push button on the end of it. 3. Review of Resident #35's Face Sheet revealed the facility admitted the resident on 11/03/2021 with diagnoses to include: Major Depressive Disorder, recurrent severe without psychotic features, Difficulty in walking and weakness. Review of Resident #35's Annual Minimum Data Set (MDS) Assessment, dated 12/23/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fourteen (14) out of fifteen (15) indicating intact cognition. During an observation of Resident #35, on 02/20/2024 at 1:40 PM, he/she was observed yelling Hello from his/her room. When the surveyor entered the room, Resident #35 stated he/she needed a blanket and was cold, but could not reach his/her call light. Further observation revealed the call light was hanging on the wall and attached to the call light cord, but was not within reach for the resident to call for assistance. During an interview with Certified Nursing Assistant (CNA) #1, on 02/20/2024 at 1:40 PM, he stated he was unaware the call lights for Residents #17 and #35 were not functioning. CNA #1 proceeded to test both Bed A and Bed B's call lights for Resident #17 and #35 and determined neither were working. The CNA stated he would write it down in the maintenance book at the nurse's station and would also verbally notify the Maintenance Director in order to have the call lights repaired quicker. During an interview with CNA #2, on 02/20/2024 at 2:45 PM, she stated she did not know the Resident's call lights were not working and did not know what the residents would do if they needed help. During an interview with Licensed Practical Nurse (LPN) #1 on 02/20/2024 at 2:20 PM, he stated he did not know the call lights in room [ROOM NUMBER] for Residents #17 and #36 did not work but maintenance should be notified so they could be repaired. During an interview with the Maintenance Director, on 02/22/2024 at 2:35 PM, he stated anytime equipment was in need of repair, staff should complete a maintenance repair form which was located on the 600 hall, then they should place the form in the file folder located in his office. He further stated a lot of times the staff would just verbally notify him of an issue or if something wasn't working and he would make the repairs. During an interview with the Director of Nursing (DON), on 02/23/2024 at 2:36 PM, she stated she expected the facility to have functioning call lights and for the call lights to be in reach of the residents. The DON stated the facility could supply a bell for Resident #17 and #35 to ring until the call light was repaired. Further, the DON stated staff should be performing more frequent rounding to ensure the call lights were working and in reach of the resident. The DON stated if the resident was left without a means of communication, their needs would not be met. During a telephone interview with the Administrator, on 02/23/2024 at 3:10 PM, she stated if a call light was not functioning, it should be reported immediately to maintenance so the repair could be done. The Administrator stated she expected staff to report anything that was not functioning properly so alternative means could be found. She further stated a resident would not be able to communicate their needs without having access to a call light or a bell.

Based on observation, interview, facility policy review, and Crash Cart Daily check form review, it was determined the facility failed to ensure there was an effective system in place to ensure the equipment needed to provide Cardiopulmonary Resuscitation (CPR) was available on the crash cart at all times, to aide in maintaining heart and lung function until emergency transport and care arrived. The facility failed to ensure a suction machine, ambu bag, [MEDICATION(S)], and AED pads, were available on the crash cart at all times, per facility policy and Crash Cart checklist. In addition, the facility failed to ensure the oxygen tank on the cart had oxygen. The finding include: Review of the facility policy titled, Medical Emergency Response, last revised [DATE], revealed the crash cart was a specialty cart that contained emergency response equipment that would aide in maintaining heart and lung function until emergency transport and care arrived. An Automated External Defibrillator (AED) was a device that provided cardiac rhythm monitoring and electric shock to heart if indicated. Further review of the policy revealed every location would have at least one crash cart and AED available for emergency response and would be maintained for supplies and checked for operation. Further review of the policy revealed each cart should at a minimum contain the following: portable backboard, functional suction machine with appropriate tubing/suction containers, suction tubing, extension tubing for suction, [MEDICATION(S)] (tonsil tip) suction, several sizes of oral airways (small, medium. and large), Nasal cannula, simple mask, non-rebreather mask, oxygen extension tubing, box of gloves, stethoscope, blood pressure cuff, flashlight, and an oxygen E-tank with regulator. In addition, review of the facility Crash Cart check list revealed an ambu bag (artificial manual breathing unit) should also be on the crash cart. Review of the 500 Hall November and [DATE], and [DATE] Crash Cart Checklists, revealed there was no suction machine on the cart from [DATE] through [DATE] (twenty {20} days), no [MEDICATION(S)] from [DATE] through [DATE] (seven {7} days) and [DATE] through [DATE] (three {3}days), no pads for AED from [DATE] through [DATE] (four {4}days), and the oxygen tank was empty from [DATE] through [DATE] (twelve {12} days but form not filled out for ,d+[DATE] and ,d+[DATE]). Observation on [DATE] at 11:55 AM revealed the oxygen tank on the 500 Hall crash cart was still empty Review of the ,d+[DATE] Hall November and [DATE], and [DATE] Crash Cart Checklists, revealed there was no ambu bag with mask from [DATE] through [DATE], and no suction machine from [DATE] through [DATE]. Observations of 500 Hall Crash Cart on [DATE] at 11:55 AM and ,d+[DATE] Hall Crash Cart at 12:06 PM revealed the crash carts contained all items that were listed in the facility policy. Interview (Post Survey) with Licensed Practical Nurse (LPN) #1 (one of the nurses who completed crash cart checks) on [DATE] at 8:27 AM, revealed licensed staff checked the two crash carts in the building every night. LPN #1 stated there was a checklist on each cart that listed the items that should be on the cart and the cart was checked to ensure each item was on the cart. LPN #1 further revealed if an item was not on the cart, then licensed staff should replace the item, and if not available, should notify the Director of Nursing (DON) or Administrator. LPN #1 stated there was a period of time there was not a suction machine on the 500 hall crash cart but the word was as long as there was one on the other cart, there was no concern. LPN #1 further revealed they had to wait for the [MEDICATION(S)] to come in. He/she stated he/she was not aware how to go about replacing or refilling the oxygen tank, and he/she did not remember why there was a period of time there was no ambu bag. LPN #1 stated he thought Administration was aware the items were not on the cart. Attempts to interview Registered Nurse (RN) #1 on [DATE] at 12:30 PM, and [DATE] at 8:29 AM, who was the other nurse who conducted most of the crash cart checks were unsuccessful. Messages were left to return call. On [DATE] at 10:52 AM, RN #1 returned surveyor's call. RN #1 revealed the crash carts were checked every night by the licensed staff. She stated if an item was not on the cart, the licensed staff should have replaced the item or if not available, should have made Administration aware. She revealed she was told the suction machine was taken off the cart because the wrong canisters were ordered, and the [MEDICATION(S)] was on back order. She stated the oxygen tank had been out of oxygen for a while and she did not know why that had not been corrected. She further stated the DON was aware of the concerns of the Crash Cart not having the required items. Phone interview with the Medical Record/Supplies on [DATE] at 11:30 AM revealed when she checked the crash cart she was only checking to ensure the checklist had been completed the night before. She stated she was only checking the checklist on Hall 500 because she thought Activities was checking the one on ,d+[DATE] hall. She stated she was told today she was supposed to be checking both carts and making sure anything identified as not being on the cart was replaced. She stated there was an issue with obtaining an ambu bag so some were obtained from the hospital. She further revealed she thought the suction machine was somewhere else in the building. Interview with the Director of Nursing (DON) on [DATE] at 2:17 PM, revealed the night shift nurse was responsible for checking the crash carts to make sure everything on the checklist was on the cart. The DON stated the nurse should have replaced the item if he/she identified the item was not on the cart. She stated because of an issue in the past the Medical Records person was supposed to check the crash cart checklists to ensure the cart was checked every night. She stated the failure to ensure the listed items were on the cart could cause a delay in a resident receiving emergency care. Interview (Post Survey) with the DON, on [DATE], revealed she was aware there was a time the suction machine and ambu bag was not on a cart. She stated the suction machine had to do with not having canisters and there were problems with receiving them due to COVID and the supply person obtained them form the hospital. She stated the other items should have been replaced to include the oxygen as there was oxygen in the oxygen storage area.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents was care planned to address facility identified needed encouragement and cueing while eating to safely eat (Resident #1). Resident #1 was assessed and identified by Speech Therapy to need encouragement and cueing to take small bites, chew food, and not talk with food in mouth to eat safely. However, the facility failed to develop a care plan that included an intervention to provide the encouragement and cues so staff were aware. On [DATE], Resident #1 was provided a peanut butter sandwich for snack with no staff present to ensure the resident was eating safely. Resident #1 choked on the sandwich and became unresponsive, and required Cardiopulmonary Resuscitation (CPR). The findings include: Review of the facility's policy titled, Resident Assessment- Comprehensive Care Plans dated [DATE], revealed the facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental. and psychosocial needs. The comprehensive care plan must include areas assessed that indicate the resident is at risk, their strengths, or identify weaknesses per the Minimum Data Set (MDS) to assess the resident's clinical, cognitive, and functional status, and use of services. The care plan will be oriented toward preventing avoidable declines in functioning of functional levels; attempt to manage risk factors, and build on resident's strengths. Record review revealed the facility admitted Resident #1 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician Orders, dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident's diet was a 1800 Calorie, regular texture, regular liquids diet Review of a Speech Therapist Progress and Discharge Summary, dated [DATE], revealed Resident #1 met goal to safely swallow three (3) meals/snacks, thin liquids, and regular textures with as needed encouragement for small bites, to chew food, and to not talk with food in mouth. However, review of Resident #1's Comprehensive Care Plan titled, Nutritional Status dated [DATE], no interventions to address the resident's identified supervision need for encouragement/cueing to eat small bites, chew food, and not talk with food in mouth. Review of the Nursing Progress Note dated [DATE] at 10:20 PM, and interviews with Registered Nurse (RN) #1 on [DATE] at 5:55 PM and State Registered Nurse Aide (SRNA) #3, on [DATE] at 3:30 PM, revealed SRNA #3 passed out bedtime snacks on [DATE] and Resident #1 chose a peanut sandwich. SRNA #3 went down the hallway to put snack cart away when she noticed Resident #1 walking down the hallway with his/her walker. Resident #1 asked SRNA #3 for a cup of water, and then drank the water when the SRNA noticed the resident had a look of panic and was not able to talk. RN #1 attempted the [MEDICATION(S)] maneuver which was unsuccessful. The resident was lowered to the floor and CPR was initiated by the nurse, with other staff members arriving to assist. EMS arrived at the facility and resuscitated the resident and transported to the hospital after the EMS Paramedic removed contents of peanut butter sandwich with forceps which was obstructing airway. RN #1 stated she was not aware the resident required prompts or cues to slow down and chew food thoroughly before swallowing and SRNA #3 stated she worked nights and only provided nighttime snacks so she was not aware. Review of the Electronic Health Record (EHR), on [DATE] at 11:20 AM, revealed Resident #1 expired at the hospital on [DATE]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS; Section G 0110 (eating) revealed the facility assessed Resident #1 required supervision to provide oversight, encouragement or cueing; and physical assistance of set up only. Interview with Speech Therapist on [DATE] at 1:50 PM, revealed she would expect the resident's identified concerns to be reflected in a resident's comprehensive care plan. She stated this information is communicated to nurse on unit, then relayed to the Unit Manager. and it is discussed in AM meetings and IDT meetings, then determined if should be care planned. Interview with the Unit Manager, on [DATE] at 1:35 PM, revealed the resident was not care planned for eating behaviors and did not have difficulty swallowing but the resident did require supervision, prompting, and cueing with eating due to unsafe eating practices. Interview with the MDS Coordinator (MDSC), on [DATE] at 1:25 and 3:50 PM, revealed the Interdisciplinary Team (IDT) identified Resident #1 had behaviors of eating too fast and not chewing food completely before swallowing. She stated the facility failed to develop a care plan for Resident #1's unsafe food intake and address the needed cueing and encouragement not to eat fast and to chew completely. Interview with the Director of Nursing (DON), on [DATE] at 2:00 PM, revealed the resident occasionally required prompts and/or cueing for socially inappropriate behaviors of eating too fast and not chewing food completely before swallowing. She stated interventions were not put in place to address the resident needed encouragement for small bites, to chew food, and to not talk with food in mouth to meet his/her goals of safety when eating.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to provide adequate supervision to one (1) of three (3) sampled residents to prevent accidents (Resident #1). The facility identified Resident #1 would consume larger portions of food when eating and failed to chew food thoroughly before swallowing. Speech therapy determined the resident required staff encouragement to consume small bites, chew food, and to not talk with food in mouth to eat safely. However, the facility failed to put interventions in place to ensure Resident #1 had adequate supervision to ensure the resident ate small bites, chew food and not talk while eating. On [DATE], Resident #1 choked on a peanut butter sandwich. The findings include: Review of the facility's policy titled, Care Standards dated [DATE], revealed it is the policy of the facility that all incidents or accidents occurring on the premises be investigated and reported to the Administrator and/or Director of Nursing. The Director of Nursing (DON) or Clinical Leader will be alerted to a possible resident event by reviewing documentation from the resident's electronic medical record (EMR) and behavior logs during daily AM meetings with IDT (Interdisciplinary Team). Review of progress notes, observations, events, physician orders will be conducted by the DON or Clinical Leader with each AM meetings to be alerted of an incident/accident occurrence. The Plan of Care will be updated to reflect what interventions were put into place to prevent reoccurring. The policy did not address identifying risks of accidents prior to occurring. Record review revealed the facility admitted Resident #1 on [DATE] with diagnoses which included [CONDITION(S)], Major Depressive Disorder, Hypertension, Dysphagia, and Mild Intellectual Disabilities. Review of Resident #1's Physician Orders, dated [DATE], revealed an order for Speech Therapy (ST) to evaluate and treat for Dysphagia re-education skill development. Further review revealed the resident's diet was on a 1800 Calorie, regular texture, regular liquids diet. Review of the Speech Therapy (ST) Plan of Care (POC) dated [DATE] revealed the reason for referral was change in intake safety and difficulty with liquids and safety, needs skilled ST analysis and possible interventions. Review of the Speech Therapist Progress and Discharge Summary, dated [DATE], revealed Resident #1 met goal to safely swallow three (3) meals/snacks, thin liquids, and regular textures with as needed encouragement for small bites, to chew food, and not talk with food in mouth. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS; Section G 0110 (eating) revealed the facility assessed Resident #1 required supervision to provide oversight, encouragement or cueing; and physical assistance of set up only. Review of Resident #1's Comprehensive Care Plan titled, Nutritional Status dated [DATE] revealed it did not address the resident's identified need of supervision to encourage resident to eat small bites, chew food, and not talk with food in mouth. Review of the Resident #1's Progress Note, dated [DATE] at 10:20 PM, revealed Resident #1 ate a peanut butter sandwich as a bedtime snack. The resident choked on the sandwich and became unresponsive requiring Cardiopulmonary Resuscitation (CPR). Further review revealed Emergency Medical Services (EMS) was dispatched to the facility and the resident was resuscitated at the facility and transported to the hospital. Review of the Electronic Health Record (EHR), on [DATE] at 11:20 AM, revealed Resident #1 expired on [DATE]. Interview with Speech Therapist on [DATE] revealed Resident #1 received Speech Therapy treatments [DATE] through [DATE]. The Speech Therapist stated upon reviewing Resident #1's therapy treatment notes, the resident was evaluated and treated due to behaviors of eating too fast and not chewing food completely before swallowing. Further interview revealed Resident #1 was evaluated and educated by speech therapy on eating behavior manners and socialization skills and appropriateness. She stated the ST goal was education related to consuming smaller portions of food and increased chewing of food. Interview with State Registered Nurse Aide (SRNA) #3, on [DATE] at 3:30 PM, revealed she passed out bedtime snacks on [DATE]. SRNA #3 stated Resident #1 would usually eat cheese and crackers for bedtime snack; however, he/she chose a peanut sandwich that night. SRNA #3 revealed she went down the hallway to put snack cart away when she noticed Resident #1 walking down the hallway with his/her walker. She revealed the resident asked me for a cup of water, I poured the water, gave it to the resident, he/she drank the water and I noticed he/she had a look of panic, and at that point he/she was not able to talk. I yelled for the nurse, who was in the room beside where we were standing in the hallway. The nurse came onto the hallway and attempted the [MEDICATION(S)] maneuver which was unsuccessful. At that point, the resident began to go down; and the nurse and I eased the resident to the floor. She stated CPR was initiated by the nurse, other staff members arrived to assist, and EMS was dispatched to the facility. She revealed she was not aware the resident required cues or prompting with food because she worked nights and bedtime snacks was the only time she observed the resident eating. Interview with Registered Nurse (RN) #1, on [DATE] at 5:55 PM, revealed SRNA #3 informed her Resident #1 was choking and she approached the resident and attempted the [MEDICATION(S)] maneuver which was unsuccessful. RN #1 stated Resident #1 became unresponsive, and she and SRNA #3 eased the resident to the floor, and initiated CPR. RN #1 revealed other staff members arrived to assist, and EMS was dispatched to the facility. She stated Resident #1 was resuscitated and transported to the hospital after the EMS Paramedic removed contents of peanut butter sandwich with forceps which was obstructing airway. RN #1 stated, the resident would consume food fast and not chew food completely; however, she did not recall if the resident had ever choked. RN #1 stated she was not aware the resident required prompts or cues to slow down and chew food thoroughly before swallowing. She revealed Resident #1 was not care planned for safe swallowing and/or to monitor during eating and swallowing in attempt to manage risk factors. Interview with the EMS Paramedic, on [DATE] at 11:56 AM, revealed EMS was dispatched to the facility on [DATE] at 8:07 PM and arrived with resident contact at 8:11 PM. The EMS Paramedic stated CPR was in process when they arrived but ventilation could not get into airway. He revealed he had to use forceps to remove contents of peanut butter sandwich and clear the resident's airway. The resident was then intubated and EMS staff used a bag valve mask (BVM) with high flow oxygen to ventilate the resident. He stated after two (2) minutes of CPR the resident had a strong pulse, and was transferred onto the stretcher for transport to the emergency room . Interview with the Director of Nursing (DON), on [DATE] at 2:00 PM, revealed Resident #1 was evaluated and determined not to have problems with swallowing. The DON stated the resident occasionally required prompts and/or cueing for socially inappropriate behaviors of eating too fast and not chewing food completely before swallowing. She stated the resident was independent with meals and only required staff to set up his/her tray.

Based on interview, record review, and facility policy review, it was determined the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for use when needed for one (1) of three (3) sampled residents (Resident #1). On [DATE], Resident #1 choked on a peanut butter sandwich and became unresponsive. In attempt to suction the resident, it was discovered the suction machine was not functioning and unable to remove contents lodged in the resident's airway. The findings include: Review of the facility's policy titled, Medical Emergency Response, dated [DATE], revealed every location will have at least one Crash Cart and Automated External Defibrillator (AED) available for emergency response and maintained for supplies and checked for operation. Review of the Crash Cart Checklist revealed the cart is to be checked every night by the nurse. The suction machine and flash light are to be checked for working at this time also. When the crash cart is used, the nurse using the cart will restock immediately. Record review revealed the facility admitted Resident #1 on [DATE] with diagnoses which included [CONDITION(S)], Major Depressive Disorder, Hypertension, Dysphagia, and Mild Intellectual Disabilities. Review of the Resident #1's Cardiovascular Events-Cardiopulmonary Resuscitation (CPR) form, dated [DATE] at 9:33 PM, revealed the resident was walking down the hallway when a staff member shouted she's choking. The [MEDICATION(S)] maneuver was attempted without success. The resident became unresponsive, and was eased to the floor, and CPR was initiated. Staff responded, and a State Registered Nurse Aide (SRNA) brought the Crash Cart. Further review of the form revealed the suction machine was not performing properly and a staff member had to get a crash cart from another unit. Interview with Registered Nurse (RN) #1 on [DATE] at 5:55 PM revealed the suction machine did not function properly and another crash cart was obtained with an operational suction machine. Interview with the Director of Nursing (DON), on [DATE] at 2:00 PM, revealed the suction machine on the first crash cart did not function properly so she had the staff discard it. She stated there were other suction machines available for use. She stated the Crash Cart was last checked on [DATE] however, she did not know if the nurse assessed to determine if there was proper suction when turned on. She stated she would not expect staff to check suction of machine because the use of a cannula would be wasteful.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective antibiotic stewardship program for one (1) of twenty-two (22) sampled residents (Resident #75). On 11/03/19, Resident #75 was ordered to receive an antibiotic for an infected wound. However, staff interview and review of a Skin McGeer Criteria form (utilized by the facility to determine the eligibility for a resident to receive an antibiotic) revealed the resident did not meet the criteria for antibiotic therapy. However, there was no evidence that Resident #75's physician had been notified that the resident did not meet the criteria for use of an antibiotic. The findings include: Review of the facility's policy titled, Infection Control Program, dated (MONTH) (YEAR), revealed the facility would utilize McGeer criteria to assist in the recognition of infections and to ensure antibiotic usage was appropriate as part of their Antibiotic Stewardship Program. Observation of a skin assessment by Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 for Resident #75 on 12/05/19 at 10:50 AM revealed an unstageable pressure ulcer was observed to the resident's right buttock, which measured 6.5 centimeters (cm) in length, by 4.5 cm in width by 5 cm in depth. Approximately 75 percent of the wound bed was observed to have necrotic tissue with 25 percent of the wound bed observed to have granulation tissue. The pressure ulcer was observed to have a very foul odor. Review of the medical record for Resident #75 revealed the facility admitted the resident on 07/27/15, with [DIAGNOSES REDACTED]. The medical record further revealed the resident was to have comfort measures. Review of the most current Minimum Data Set (MDS) annual assessment dated [DATE], revealed the facility had assessed the resident to have severely impaired cognition, and was therefore not interviewable. The MDS also revealed the facility had assessed the resident to have an unhealed unstageable pressure ulcer. In addition, the MDS stated the facility had assessed the resident to require the total assistance of two (2) persons for bed mobility, transfers, and toileting. Review of the comprehensive person-centered care plan for Resident #75 with a revision date of 11/19/19, revealed staff would provide treatment to the pressure ulcer as ordered by the physician, and assess the pressure ulcer for the location, stage, size, presence or absence of granulation tissue and [MEDICATION NAME], and condition of surrounding tissue. Review of the nurse's notes for Resident #75 by LPN #1 dated 11/03/19 at 12:56 PM, revealed that during the resident's dressing change to the pressure ulcer on the resident's right buttock the wound had opened with a large amount of serosanguineous drainage being observed to the old dressing and draining from the wound. The nurse's note revealed the drainage was observed to be brown and yellow in color and had an odor present. Further review of the nurse's notes revealed an entry by LPN #1 on 11/03/19 at 6:06 PM that an order had been received from Advanced Practice Registered Nurse (APRN) #1. The APRN ordered the resident to receive Bactrim DS 800 milligrams (mg) per 160 mg (antibiotic) twice daily for ten (10) days for an infected wound to the resident's right buttock. Review of Resident #75's physician orders [REDACTED]. buttock. Review of a Skin McGeer Criteria form completed by the Infection Control Nurse for Resident #75 dated 11/03/19 at 1:59 PM, revealed the resident did not meet the criteria for antibiotic therapy. However, there was no evidence that Resident #75's physician had been notified that the resident did not meet the criteria for use of an antibiotic. Review of the Medication Administration Record [REDACTED]. Interview conducted with Advanced Practice Registered Nurse (APRN) #1 on 12/05/19 at 2:50 PM, revealed she had given LPN #1 the order for the antibiotic for Resident #75. The APRN stated that if the staff had notified her that the resident had not met the criteria for antibiotic therapy she would have ordered a wound culture. Interview conducted with LPN #1 on 12/05/19 at 2:55 PM, revealed she had notified APRN #1 when she observed the drainage and foul odor on Resident #75's pressure ulcer to the right buttock. The LPN stated the APRN had not requested laboratory testing be done to ensure the appropriate antibiotic was being administered. The LPN stated the responsible party would often refuse venipunctures, but felt the responsible party would have agreed with doing a wound culture if he/she had been asked. Interview conducted with RN #1 on 12/05/19 at 2:59 PM, revealed she was the Unit Manager for the 600 Unit. The RN stated Resident #75's physician should have been notified when the resident did not meet criteria to receive an antibiotic. The RN stated the physician should have been notified to see if perhaps a culture could be completed. Interview conducted with the Infection Control Nurse (ICN) on 12/05/19 at 3:09 PM revealed she had completed the McGeer Skin Criteria form for Resident #75. The ICN stated the resident had not met the appropriate criteria to receive an antibiotic. The ICN stated the physician should have been notified for additional orders after it was determined that the resident had not met the criteria to receive antibiotic therapy. The ICN stated she should have notified the physician and guessed it was just an oversight. The ICN stated all residents with new antibiotic orders, laboratory specimens, and infections were discussed in the morning clinical meeting. The ICN stated she recalled discussing Resident #75 not meeting the requirements for antibiotic therapy; however, she could not recall what had been done. Interview conducted with the Director of Nursing (DON) on 12/05/19 at 3:27 PM, revealed all infections were discussed daily in the morning clinical meeting. The DON revealed all nurse's notes and physician's orders [REDACTED]. The DON stated she had looked at Resident #75 and since the physician had not ordered any laboratory testing they had not questioned the order and she guessed they should have notified the physician.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observations on [DATE] revealed a visibly dirty can opener, expired foods, foods not sealed and dated, and improper food handling. Review of the Census and Condition, dated [DATE], revealed seventy-one (71) of seventy-one (71) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Storage Procedures, last revised (MONTH) (YEAR), revealed food should be covered, dated and stored loosely to permit circulation of air. It further stated all foods in the freezer are to be wrapped in a moisture proof wrapping or sutiable container, labeled and dated with use-by dates clearly marked. Observation of the kitchen walk-in freezer on [DATE] at 09:43 AM, revealed three (3) packs of soft shell tortillas present with a use by date of (MONTH) (YEAR), a large plastic bag of frozen peas open to air with no labeling or date present, and a large bag with large tear in the paper bag exposing the content of the bag which were french fries. 2. Review of facility policy titled Glove Usage By Dietary, last revised (MONTH) (YEAR), revealed staff are to never handle food with their bare hands or gloved hand while serving. Observation of lunch tray-line on [DATE] at 11:40 AM, revealed Dietary Aide #1 used her gloved hand to place bread on ten (10) different trays she was setting up for the residents after she had touched the tray carts and gathered equipment throughout the kitchen. 3. Observation of the kitchen on [DATE] at 11:36 AM, revealed the kitchen's manual can opener was visibly soiled with a blackish brown moist looking buildup on the cutting edge and the area surrounding the cutting edge. Interview with the Dietary Manager on [DATE] at 11:16 AM, revealed she expected the staff to ensure foods are labeled appropriately with used by and expired dates. She stated she expected foods to be stored properly with a complete sealing of the item and to have appropriate labeling. She further stated she expected the can opener to be cleaned after each use or when visibly soiled and she expected staff to use utensils when handling foods and to not use their hands for handling foods.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents, (Resident #52), received an accurate assessment reflective of the resident's status at the time of the assessment. Resident #52 was readmitted from the hospital on [DATE]; however, review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/22/18, revealed the facility failed to accurately code, Section I: Active Diagnoses, of the RAI with the resident's diagnoses. The findings include: Review of the RAI Version 3.0 User Manual, Section I: Active Diagnoses, revealed the intent of the items in this section were intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavioral status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Record review revealed the facility readmitted Resident #52 on 07/27/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/22/18, revealed UTI was the only [DIAGNOSES REDACTED].#52's Annual MDS, Section I- Active Diagnoses, dated 05/31/18, revealed the following [DIAGNOSES REDACTED]. Interview with the MDS Coordinator, on 09/21/18 at 2:35 PM, revealed current [DIAGNOSES REDACTED].#52's current status should have been coded on the RAI/MDS. The MDS Coordinator stated she expected the RAI/MDS to reflect an accurate status of Resident #52's status during the assessment and she uses the RAI manual for instructions when conducting MDS assessments. Interview with the Director of Nursing (DON), on 09/21/18 at 2:55 PM, revealed she expected Resident #52's [DIAGNOSES REDACTED]. The DON stated she expected the MDS Coordinator to code resident assessments as indicated in the RAI manual.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan implemented to meet the resident's medical, physical, mental, and psychological needs for two (2) of nineteen (19) sampled residents, (Resident #26, Resident #52). Resident #52 was hospitalized from [DATE] through 07/27/18 with [DIAGNOSES REDACTED]. In addition, Resident #26's family repeatedly brought in over the counter medications/treatments for the resident; however, the facility failed to revise the resident's care plan to address the situation. The findings include: Review of the facility's policy and procedures, Comprehensive Resident Care Plan, Chapter 3.5, dated (MONTH) (YEAR), reference F656, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the Minimum Data Set (MDS). Assessments of residents are ongoing and care plans are revised as information about the resident's condition change. 1. Record review revealed the facility readmitted Resident #52 from the hospital on [DATE] with [DIAGNOSES REDACTED]. However, review of Resident #52's Comprehensive Care Plan, last revised 08/03/18, revealed the facility failed to revise the resident's care plan to address the resident's history of UTI, Pneumonia, [MEDICAL CONDITION]. 2. Record review revealed the facility admitted Resident #26 on 06/02/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/09/18 revealed the facility assessed Resident #26's cognition to be intact with a Brief interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Observation and interview on 09/19/18 at 9:34 AM revealed there was a tube of [MEDICATION NAME] with no label and a roll of plastic wrap on the end table in Resident #26's room. Resident #26 stated he/she puts [MEDICATION NAME] cream on his/her [MEDICAL TREATMENT] shunt site and wraps it in plastic wrap thirty (30) minutes before going to [MEDICAL TREATMENT] to prevent pain. Interview with the Unit Manager and Registered Nurse (RN) #1, on 09/21/18 at 11:00 AM revealed the family frequently brings in medications and treatments to Resident #26 without making staff aware, but had been educated on this not being allowed. However, review of Resident #26's Comprehensive Care Plans, dated 07/11/18 revealed there was no care plan developed to address the family's non-compliance related to bringing in over the counter medications/treatments even though this was not the first time the family had brought them in. Interview with the MDS Coordinator, on 09/21/18 at 2:35 PM, revealed resident care plans are implemented based on resident care needs and resident's RAI/MDS. The MDS Coordinator stated Resident #52's comprehensive care plan was reviewed on 08/03/18; however, she failed to implement a care plan related to history of UTI, Pneumonia, [MEDICAL CONDITION]. The MDS Coordinator revealed it is her responsibility to ensure the resident's comprehensive care plans are implemented based on the care needs. Interview with the Director of Nursing (DON), on 09/21/18 at 2:55 PM, revealed resident care planning is an Interdisciplinary approach. The DON stated she expected each resident's care plan to be updated as resident's condition change and it was the responsibility of the MDS Coordinator to ensure medical and nursing care needs are on the resident's care plan. The DON further revealed the Social Services Director was responsible to ensure a resident's mental and psychosocial care needs are implemented in the comprehensive care plan.

Based on observation, interview, record review, and review of [MEDICATION NAME]/[MEDICATION NAME] manuafacturer's enclosure, facility policy review, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (1) of nineteen (19) sampled residents (Resident #26). Observation on 09/21/18 at 10:34 AM revealed an uncapped tube of [MEDICATION NAME] on the end table by Resident #26's chair that was visible from the hallway. Further observation revealed a confused resident pacing back and forth, going pass Resident #26 The findings include: Review of the Manufacturers ensclosure for [MEDICATION NAME] and [MEDICATION NAME] cream revealed it was for topical use only, keep out of the reach of children. Further review revealed [MEDICATION NAME] and [MEDICATION NAME] cream should be used with caution in patients who may be sensitive to the systemic effects of [MEDICATION NAME] and [MEDICATION NAME] including acutely ill, debilitated, or the elderly. Observation of Resident #26's room on 09/21/18 at 10:34 AM revealed an uncapped tube of [MEDICATION NAME] on the end table and visible from the hallway, just inside the door. Plastic wrap was also noted. Observation on 09/21/18 at 10:40 AM revealed the room next to Resident #26 was occupied by a resident with Dementia that frequently wandered around the facility. Interview with Licensed Practical Nurse (LPN) #1, Charge Nurse on 09/21/18 at 10:45 AM revealed the [MEDICATION NAME] should come from pharmacy and be locked up, but the one in the room did not have a label so he was unaware of where it came from. He stated the tube also had the cap off which made it unsafe for wandering residents. Interview with the Unit Manager on 09/21/18 at 11:00 AM revealed the family frequently brings in medications and treatment to the resident without making staff aware, but had been educated on this not being allowed. She stated this could be a safety hazard because the resident's room is so close to a resident's room that frequently wanders. She further revealed no other resident's that wandered were on the hall but there was one (1) other wandering resident in the facility.

Based on interviews, record review, review of personnel time detail and review of the facility's policy and procedure, it was determined the facility failed to ensure each resident was free from verbal and physical abuse for one resident (#1) in the selected sample of four (4) residents. The facility failed to ensure residents were free from abuse and failed to ensure staff was knowledgeable of the facility ' s Abuse and Neglect and Prevention, Investigation, Resident Protection and Reporting policy and procedures. On 10/09/12 at approximately 9:00 AM, three facility staff (Certified Nurse Aide (CNA) #1, 2, 3) witnessed another staff CNA #4 physically hit and curse Resident #1, who was attempting to leave the dining room, per wheelchair. CNA #4 attempted to wheel Resident #1 beside her, as the resident was not allowed to leave the dining room unsupervised. While CNA #4 attempted to put the brakes on the resident's wheelchair, Resident #1 hit CNA #4 in the throat. CNA #4 began kicking the resident's wheelchair and cursing at him/her, making statements such as "I hate you mother [***] , that's the last time you are going to [***] ing hit me." CNA #4 hit Resident #1 in the chest and in the mouth. While staff removed the resident from the perpetrator and reported the incident alleging abuse to the Unit Manager, the facility failed to follow their policy to ensure the protection of all residents after an allegation of abuse was received. The facility allowed CNA #4 to continue to provide direct resident care until clocking out for lunch at 10:27 AM, approximately 1 1/2 hours after the incident occurred. During this time, CNA #4 was allowed to interact with Resident #1, in the resident's room. The failure to ensure residents were free from verbal and physical abuse and protect residents after an allegation of abuse was made has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The ongoing Immediate Jeopardy with substandard quality of care was determined to exist on 10/09/12. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing. (Refer to F226). Findings include: A review of the "Abuse and Neglect" policy/procedure, revised 01/08, revealed "abuse" was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. "Verbal abuse" was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. "Physical abuse" was defined as hitting, slapping, pinching and kicking; also, controlling behavior through corporal punishment. Review of the "Prevention, Investigation, Resident Protection and Reporting" policy/procedure, revised 03/09, revealed the "alleged perpetrator" must be immediately removed from resident care areas in order to protect the residents. A record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired. Interviews with CNA #1, on 10/24/12 at 10:10 AM, CNA #2, on 10/24/12 at 11:15 AM and 10/25/12 at 9:15 AM, and CNA #3, on 10/24/12 at 1:55 PM, revealed they witnessed the incident between CNA #4 and Resident #1 on 10/09/12 at approximately 9:10 AM. These CNAs revealed that Resident #1 was attempting to leave the dining room when CNA #4 wheeled the resident back to her. CNA #1 stated that CNA #4 was not "nice" to the resident and made the statement "You are not going back right now, you are going to have to wait." Resident #1 continued to attempt to leave the dining room so CNA #4 put the brakes on the wheelchair. In the process, Resident #1 punched CNA #4 in the throat. The CNAs witnessed CNA #4 kicking the resident's wheelchair at that time. CNA #1 also witnessed CNA #4 kicking the resident's leg. CNA #1 revealed that CNA #4 stated to the resident #1 "I hate you mother [***] , that's the last time you are going to [***] ing hit me." CNA #2 stated, CNA #4 kicked at the resident's wheelchair while cursing at the resident, making statements such as "You are not going to hit me like this [***] ing again, I hate your god damn guts." She described it as like a "kid having a tantrum." CNA #3 revealed CNA #4 made statements such as "I [***] ing hate you" towards Resident #1. These CNAs further revealed that CNA #4 attempted to put the brakes on the resident's wheelchair again and the resident reached back to hit CNA #4. CNA #4 hit Resident #1 in the chest with her open hand and stated, "You are not going to hit me again." The resident continued to state," I'm ready to go, I want out of here. " CNA #4 physically held the resident's hands down in an effort to put the brakes on the wheelchair when the resident reached down to bite CNA #4. CNA #4 "smacked" Resident #1 in the mouth. The CNAs revealed that CNA #2 removed the resident from the dining room, taking him/her to the nurse's station and CNA #3 reported the incident to Unit Manager #1 shortly afterwards. An interview with CNA #4, the alleged perpetrator on 10/24/12 at 11:35 AM, revealed Resident #1 punched her in the throat and she grabbed the resident's arm to stop him/her from hitting her a second time. She denied hitting the resident. She denied cursing the resident; however, stated she "hated" the way he/she was acting. She verified the incident occurred on 10/09/12, sometime between 8:30 AM and 9:00 AM. An interview with Unit Manager #1, on 10/24/12 at 2:30 PM, revealed she was the supervisor in charge of the facility on 10/09/12. At approximately 8:45 AM, CNA #3 approached her and reported an allegation. She was informed that CNA #4 had cursed and hit Resident #1 in the chest. She stated that CNA #3 was not the most " reliable" source so she proceeded to the dining room to question CNA #1 about the allegation. She stated that CNA #1 did not want to discuss the allegation because CNA #4 was still in the dining room transporting residents back to their rooms. She admitted CNA #4 was not removed from resident care and stated "I wanted to make sure what was going on before confronting her." She revealed Resident #1 was not assigned to CNA #4; therefore Resident #1 was safe. She revealed she was not aware of the facility's abuse policy requiring the removal of an "alleged perpetrator" from resident care areas and verified she did not know what to do in the situation. An interview with the Minimum Data Set (MDS) Coordinator, on 10/25/12 at 11:30 AM, revealed Unit Manager #1 reported in the "morning meeting" the allegation of CNA #4 hitting Resident #1. She stated that they were trying to determine if it "actually" happened, as there was animosity between some of the staff members. We discussed that if the incident occurred, CNA #4 needed to go home. She revealed CNA #4 was not taking care of Resident #1; therefore, Resident #1 was "out of harm's way." She was not knowledgeable of the abuse policy other than reporting to a supervisor. An interview with LPN #2, on 10/25/12 at 10:00 AM, revealed she was the nurse working the unit with CNA #4 on 10/09/12. When made aware of the abuse allegation, she informed staff that CNA #4 needed to go home. She was informed that Unit Manager #1 was "taking care of it." Continued interviews with CNA #1, #2, #3, LPN #2, Unit Manager #1 revealed the facility continued to allow CNA #4 to provide care to residents after the incident for approximately 1 ? hours after the incident. During this period of time, interview with LPN # 1, on 10/24/12 at 4:05 PM, revealed she was the nurse assigned to Resident #1 on 10/09/12. After the incident in the dining room, she placed a call to the resident's sister asking her if she could come "calm" the resident down. She informed the resident's sister that Resident #1 hit a nurse aide and was having some behavioral issues in the dining room; however, she was not made aware of the alleged abuse towards Resident #1. Interview with Resident #1's sister, on 10/25/12 at 10:25 AM, revealed the facility called her on 10/09/12 to "calm" Resident #1 down as he/she had hit a nurse aide in the dining room. Upon arrival to the facility, she went over to the unit where CNA #4 worked, asking her to come to Resident #1's room. She asked the resident in front of CNA #4 if he/she had hit her; however, the resident denied the allegation. CNA #4 admitted the resident hit her in the throat. She revealed the resident continued to deny the allegation; therefore, she apologized to CNA #4 for the resident's actions. Continued interview with CNA #4 revealed she continued to provide care to residents of the facility until clocking out for lunch at approximately 10:30 AM. CNA #4 verified that Resident #1's sister asked her to come to Resident #1's room and apologized for the resident's actions. A review of the Time Detail, dated 10/09/12, revealed CNA #4 clocked out for lunch at 10:27 AM, returned at 11:03 AM, and ended her shift at 11:13 AM. An interview with the DON, on 10/25/12 at 12:35 PM, revealed she was not in the facility on 10/09/12; however, she had instructed Unit Manager #1 to remove CNA #4 from resident care as this allegation was serious. She expected Unit Manager #1 to remove the "alleged perpetrator" prior to contacting her or the Administrator. An interview with the Administrator, on 10/25/12 at 1:00 PM, revealed she was at a different facility on 10/09/12. During her investigation, she was made aware Unit Manager #1 did not follow the policy related to the protection of residents. She expected the supervisor to remove CNA #4 from care immediately. The facility's investigation substantiated the allegation of abuse and CNA #4 was terminated 10/11/12. While the facility terminated the perpetrator, the facility could provide no documented evidence that they had initiated corrective action to prevent the recurrence of abuse, to ensure staff was knowledgeable and competent related to facility policies and procedures and necessary action staff should take for abuse prevention and protection of residents after an alleged allegation of abuse was received. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing.

Based on interview and record review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 10/29/12, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related to staff knowledge of the facility's Abuse/Neglect and Prevention, Investigation, Resident Protection, and Reporting policies and procedures. Findings include: Review of the acceptable Allegation of Compliance (AoC), dated 11/09/12, revealed all residents were assessed for bruising, injuries, and behavior changes on 10/25/12. The assessments were completed by the Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) unit manager, Licensed Practical Nurse (LPN) unit manager, and 600 unit LPN after being trained by the Regional Director of Operations (RDO). The Director of Social Services spoke to 22 interviewable residents and 52 family members related to abuse/neglect in the facility and ensured they were aware of how to report. All staff received education on the facility's Abuse and Neglect policy as well as recognition of "stressed staff." To verify understanding, the staff completed a post competency test related to all aspects of the abuse and neglect policy and expectations. The test was given by the DON, Administrator, Human Resources Director, or Social Services Director. Any staff not achieving 100% was provided re-education by the DON or Administrator and retested . To ensure all residents, staff, families, and vendors were aware of what to do if abuse was suspected, new signs in general viewing areas were placed to indicate the facility as an abuse free zone. The facility developed and implemented verification sheets to document rounds every two hours by the Compliant Officer. The rounds consist of visualizing each resident every two hours to observe for potential signs of abuse. An interview with the Administrator, on 11/14/12 at 1:20 PM, revealed the facility had not submitted an acceptable Plan of Correction (PoC).

Based on interviews, the facility's final investigation, and review of the "Prevention, Investigation, Resident Protection and Reporting" policy and procedure, it was determined the facility failed to implement written policies and procedures that prohibit abuse for one resident (#1) in the selected sample of four residents. The facility failed to ensure staff was trained and competent regarding their knowledge of the facility's Prevention, Investigation, Resident Protection and Reporting policy and procedure. The facility failed to ensure protection of residents after an allegation of abuse, conducting a thorough investigation, and ensuring screening processes were followed to ensure appropriate persons were hired to staff the facility and prevent potential abuse. On 10/09/12 at approximately 9:00 AM, an incident occurred between Certified Nurse Aide (CNA) #4 and Resident #1. Resident #1 hit CNA #4 in the throat after she would not let the resident leave the dining room. Three staff members witnessed CNA #4 kicking the resident's wheelchair and cursing at him/her, making statements such as "I hate you mother [***] , that's the last time you are going to [***] ing hit me." CNA #4 then hit the resident in the chest and in the mouth. The facility failed to ensure resident protection after an allegation of physical and verbal abuse. The facility allowed CNA #4 to continue providing care to residents for approximately 1 ? hours after the incident, having continued contact with Resident #1 during that time. The facility failed to conduct a thorough investigation of the 10/09/12 abuse allegation. The investigation did not identify or address the staff failure to follow the facility's policy related to the protection of residents. This failure prevented the facility from ensuring staff knowledge and competency of their protections policies. While the facility's investigation substantiated that the abuse did occur, which resulted in the facility terminating CNA #4 on 10/11/12, the facility administration allowed CNA #4 to return to the facility and visit other residents, on 10/23/12. Additionally, the facility failed to ensure eight employees were screened for a history of abuse, neglect or mistreating residents prior to employment. The failure to conduct a thorough investigation and ensure the protection of residents after an allegation of abuse has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The Immediate Jeopardy with substandard quality of care was determined to exist on 10/09/12. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing. (Refer to F223, F490) The Findings Include: Review of the "Prevention, Investigation, Resident Protection and Reporting" policy/procedure, revised 03/09, revealed the Administrator and Director of Nursing (DON) were to coordinate completion of a full investigation, including actions taken to correct the situation and a plan of action to prevent further occurrences. The "alleged perpetrator" must be immediately removed from resident care areas in order to protect the residents. The supervisor would assign a staff person in a superior position to remain with the "alleged perpetrator" until an interview could be conducted. The "alleged perpetrator" would be suspended pending conclusion of the investigation and not allowed on facility premises. A review of the facility's final investigation, dated 10/12/12, revealed an allegation of abuse was reported on 10/09/12 to Unit Manager #1. On 10/09/12 at approximately 9:00 AM, an incident occurred between CNA #4 and Resident #1. Resident #1 hit CNA #4 in the throat after she would not let the resident leave the dining room. Three staff members witnessed CNA #4 kicking the resident's wheelchair and cursing at him/her, making statements such as "I hate you mother [***] , that's the last time you are going to [***] ing hit me." CNA #4 then hit the resident in the chest and in the mouth. The investigation revealed Unit Manager #1 obtained a statement from CNA #4 and suspended her pending investigation. However, interview with Unit Manager #1, on 10/24/12 at 2:30 PM, revealed she was the supervisor in charge of the facility on 10/09/12. CNA #3 reported to her an allegation of abuse at approximately 8:45 AM. She was informed that CNA #4 had cursed and hit Resident #1 in the chest. She revealed she did not consider CNA #3 to be the most "reliable" source and she wanted to "make sure what was going on" before confronting CNA #4. She revealed that she allowed CNA #4 to continue to provide resident care after the allegation was reported, stating Resident #1 was not assigned to CNA #4; therefore, Resident #1 was safe. She stated that she was not knowledgeable of the abuse policy and did not know what to do in the situation. She discussed the allegation in the facility's "morning meeting" and witness statements were obtained thereafter. She stated "three staff saying the same thing seemed a better source than just one. She revealed CNA #4 clocked out for lunch at approximately 10:30 AM and was sent home upon her return. The MDS Coordinator, on 10/25/12 at 11:30 AM, revealed she was made aware of the abuse allegation on 10/09/12, during the "morning meeting." She stated that we were trying to determine if it "actually" happened, as there was animosity between some of the staff members. She revealed CNA #4 was not taking care of Resident #1; therefore, Resident #1 was "out of harm's way." She revealed she did not know the abuse policy other than reporting to a supervisor. Interview with Licensed Practical Nurse (LPN) #2, on 10/25/12 at 10:00 AM, and continued interview with the MDS Coordinator revealed that LPN #2 was concerned about the seriousness of the allegation; however, the MDS Coordinator informed LPN #2 they were going through the proper channels and getting witness statements. She told LPN #2 "If it happened, we would pull her from the floor." The MDS Coordinator stated that she was not aware that she should remove the "alleged perpetrator" from care immediately. Interview with Resident #1's sister, on 10/25/12 at 10:25 AM, revealed the facility called her on 10/09/12 and informed her that she was needed to "calm" Resident #1 down. The facility staff informed her that Resident #1 had "hit" a nurse aide; however, provided no further details regarding the incident. The resident's sister found CNA #4, they both went to Resident #1's room, where the resident's sister questioned the resident about hitting the CNA. She stated Resident #1 denied hitting CNA #4; however, CNA #4 admitted the resident hit her in the throat. The resident's sister apologized to CNA #4 for the actions of Resident #1. An interview with CNA #4, on 10/24/12 at 11:35 AM, verified she went to Resident #1's room after the incident on 10/09/12 and the resident's sister apologized for what happened. Further interview with the Resident's sister revealed that the facility had not informed her that CNA #4 had hit Resident #1 as of 10/25/12 she had only been told that Resident #1 had hit CNA #4 and that the CNA was terminated because staff should not "get into it" with a resident. Further review of the facility's investigation revealed there was no documented evidence the facility had identified that CNA #4 had further contact with Resident #1 on 10/09/12 after the incident occurred or that staff had not informed the family of the allegation of abuse towards Resident #1. Further interview with CNA #4 revealed she provided care to residents until clocking out for lunch at approximately 10:30 AM. Continued interview with the Unit Manager #1, revealed that CNA #4 was allowed to continue to provide care. A review of the Time Detail, dated 10/09/12, revealed CNA #4 clocked out for lunch at 10:27 AM, returned at 11:03 AM, and ended her shift at 11:13 AM, two hours after the incident occurred at 9:00 AM. Further review of the investigation revealed there was no evidence that the facility had identified that the staff allowed CNA #4 to continue to provide direct resident care for approximately 1 ? hours after the allegation. An interview with the DON, on 10/25/12 at 12:35 PM, revealed she was not in the facility on 10/09/12; however, she received a text message from Unit Manager #1 regarding the allegation. She revealed Unit Manager #1 was informed to remove CNA #4 from resident care as this allegation was serious. She expected Unit Manager #1 to have removed the "alleged perpetrator" prior to contacting her or the Administrator. An interview with the Administrator, on 10/25/12 at 1:00 PM, revealed she was at a different facility on 10/09/12. She was made aware the facility had left a message for her to call related to an abuse allegation. She returned the call and informed the facility she was on her way; however, the "alleged perpetrator" had already left the building. She expected the supervisor to remove CNA #4 from care immediately (as soon as it happened). During her investigation, she was made aware Unit Manager #1 did not follow the policy related to the protection of residents; however, she revealed it was not addressed in the investigation. Furthermore, there was no documented evidence in the facility's investigation that detailed the facility had initiated corrective measures to ensure staff was knowledgeable and competent of the facility's "Prevention, Investigation, Resident Protection and Reporting" policy and procedure and abuse policy. The Administrator stated there were no corrective measures taken to ensure staff was aware of the abuse policy. The facility's investigation substantiated the allegation of abuse and CNA #4 was terminated 10/11/12. An interview with Resident #2, on 10/25/12 at 3:30 PM, revealed CNA #4 visited him/her "the other night;" however, a nurse had to supervise the visit. An interview with Registered Nurse (RN) #1, on 10/26/12 at 11:20 AM, revealed she was working second shift on 10/23/12. CNA #4 was on her way to visit the residents of the facility and she was unsure what to do in the situation. She notified the DON who instructed her to ensure supervision while CNA #4 was in the building. She verified CNA #4 visited four different residents in the facility. An interview with the DON, on 10/26/12 at 11:55 AM, revealed she was called by "someone" in the facility and asked if CNA #4 could visit some of the residents. She authorized the visit; however, requested supervision by staff while CNA #4 was in the building. An interview with the Administrator, on 10/26/12 at 12:30 PM, revealed she was not aware of CNA #4 visiting residents in the facility after termination. She stated that it was not appropriate without her knowledge. She further revealed staff should not be pulled from resident care to supervise CNA #4 in the facility. An interview with the Director of Operations, on 10/29/12 at 2:30 PM, revealed CNA #4 should not have been allowed back in the building after termination on 10/11/12. 2. A review of the "Active Employee Personnel Files" policy/procedure, revised 04/05, revealed hourly and management employee personnel files, below the Administrator level, were to be securely maintained within the facility/office. Files of the Administrator would be securely maintained in the Corporate Headquarters. A review of the "Background Checks" policy/procedure, revised 05/05, revealed the facility human resource representative would be responsible for ensuring compliance with state laws and Company policies regarding employment of individuals with criminal and/or abuse records. Criminal and abuse background inquiries should be maintained in a secure file, separate from the employee personnel files. A review of a list of new employees, dated 06/24/12-10/24/12, revealed the facility hired eight employees in the last four months. The facility was unable to provide personnel records on the eight employees, including the Administrator (hired 09/10/12). An interview with Human Resources, on 10/29/12 at 2:40 PM, revealed she was responsible for maintaining personnel records. She was unable to locate the eight new employee files; therefore, had no record of an abuse registry check or background check prior to employment. An interview with the Administrator, on 10/29/12 at 2:45 PM, revealed she was unable to locate the personnel files for the eight new employees. The facility's investigation substantiated the allegation of abuse and CNA #4 was terminated 10/11/12. While the facility terminated the perpetrator, the facility could provide no documented evidence that they had initiated corrective action to prevent the recurrence of abuse, to ensure staff was knowledgeable and competent related to facility policies and procedures and necessary action staff should take for abuse prevention and protection of residents after an alleged allegation of abuse was received. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing.

Based on interviews, record review, and the facility's policy/procedure, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of four residents (Resident #1). The facility failed to ensure staff followed the " Prevention, Investigation, Resident Protection and Reporting " policy/procedure related to the protection of residents and investigation of an allegation of abuse. On 10/09/12, facility staff reported to the Unit Manager that Certified Nurse Aide (CNA) #4 cursed and hit Resident #1. The Unit Manager failed to remove CNA #4 from resident care immediately after the allegation. CNA #4 had interaction with Resident #1 and continued to provide direct care to other residents after the incident on 10/09/12. While the facility's investigation determined abuse occurred and terminated CNA #4, the facility's investigation did not address the Unit Manager's failure to initiate protection of residents from further abuse as CNA #4 continued to work until 10:27 AM, approximately 1 ? hours after the allegation was reported. The Administrator's failure to administer the facility in a manner that enabled it to use its resources to ensure policy and procedures were implemented to ensure allegations of abuse were investigated thoroughly and residents were protected has caused or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The Immediate Jeopardy with substandard quality of care at 42 CFR 483.13 Resident Behaviors and Facility Practices was determined to exist on 10/09/12. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing. (Refer to F223, F226) Findings include: Review of the "Prevention, Investigation, Resident Protection and Reporting" policy/procedure, revised 03/09, revealed the Administrator and Director of Nursing (DON) were to coordinate completion of a full investigation, including actions taken to correct the situation and a plan of action to prevent further occurrences. The "alleged perpetrator" must be immediately removed from resident care areas in order to protect the residents. The supervisor would assign a staff person in a superior position to remain with the "alleged perpetrator" until an interview could be conducted. The "alleged perpetrator" would be suspended pending conclusion of the investigation and not allowed on facility premises. Interviews with the Unit Manager #1, on 10/24/12 at 2:30 PM, and the Minimum Data Set (MDS) Coordinator, on 10/25/12 at 11:30 AM revealed on 10/09/12 at approximately 9:00 AM, CNA #3 reported an allegation of abuse to Unit Manager #1. It was reported that CNA #4 cursed and hit Resident #1. An interview with Unit Manager #1, on 10/24/12 at 2:30 PM, revealed CNA #3 was not a "reliable source" and she needed to ensure the incident occurred before confronting CNA #4. She did not remove CNA #4 from resident care after knowledge of the allegation. She discussed the allegation with the MDS Coordinator; however, neither employee knew what to do in the situation. CNA #4 clocked out for lunch at approximately 10:30 AM, approximately 1 ? hours after the allegation. Unit Manager #1 revealed CNA #4 was not allowed back on the floor after lunch as three witness statements verifying the allegation was "better" than just one. (Refer to F223 and F226). A review of the Time Detail, dated 10/09/12, revealed CNA #4 clocked out for lunch at 10:27 AM, returned at 11:03 AM, and ended her shift at 11:13 AM. A review of the facility's investigation, dated 10/12/12, revealed the allegation of abuse was substantiated; however, did not identify or address the failure to protect residents after an allegation of abuse or detail that the facility had taken corrective measures to ensure staff knowledge and competence of the facility's abuse policy. An interview with the Administrator, on 10/25/12 at 1:00 PM and 10/29/12 at 2:45 PM, revealed Unit Manager #1 did not follow the facility's policy. She revealed Unit Manager #1 should have removed CNA #4 from resident care immediately. She acknowledged her investigation did not address these issues and no corrective measures were taken to ensure staff knowledge of the facility's abuse policy. While the facility terminated the perpetrator, the facility could provide no documented evidence that they had initiated corrective action to prevent the recurrence of abuse, to ensure staff was knowledgeable and competent related to facility policies and procedures and necessary action staff should take for abuse prevention and protection of residents after an alleged allegation of abuse was received. The facility had not submitted an acceptable Allegation of Compliance prior to the abbreviated survey exit; therefore, the Immediate Jeopardy is ongoing.

Based on interview and record review, it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 10/29/12, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related to the failure to ensure staff followed the Abuse and Neglect policy related to the prevention, investigation, resident protection, and reporting abuse. Findings include: A review of the acceptable Allegation of Compliance (AoC), dated 11/09/12, revealed the Administrator and Director of Nursing (DON) was re-educated, by the Regional Director of Operations (RDO), on 10/25/12, in regard to the seven components of the Abuse and Neglect policy including the immediate reporting to a supervisor and the immediate removal of an "alleged perpetrator" from resident care areas. The facility would implement a monthly communication meeting with all staff that emphasized resident rights and prevention of abuse. An interview with the Administrator, on 11/14/12 at 1:20 PM, revealed the facility had not submitted an acceptable Plan of Correction (PoC).