Every finding on record at Dawson Springs Health and Rehabilitation Center

Based on observation, interviews, and policy review, it was determined the facility failed to ensure information related to the Office of the State Long-Term Care Ombudsman program was posted in a manner accessible to residents and resident representatives. Observations during the survey revealed there was posted information related to the Ombudsman program located at the main entrance to the facility and that there was no further information posted anywhere else in the facility where it would be accessible to all residents. The failure to post ombudsman program information had the potential to affect all residents. The findings include:Review of the Grievance Policy, not dated, stated the facility would post in prominent locations throughout the facility, how to file grievances orally (meaning spoken) or in writing. The grievance could be filed anonymously and the contact information of the grievance official with whom a grievance could be filed, including his or her name, business address (mailing and email) and business phone number. The facility posting would include a reasonable expected time frame for completing the review of the grievance and the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program for protection and advocacy systemReview of Residents Rights policy undated, revealed the facility must provide immediate access to any resident for any representative of the Office of the State Long Term Ombudsman.Observation on 07/14/2026 at 9:00 AM revealed an Ombudsman poster containing contact information was present at the entrance of the facility, a non-residential area where all administrative offices were located. In addition, although an observation revealed a posting of the Ombudsman's name and phone number was located on a wall at the main entrance hallway, the hallway was a locked unit requiring a pin number for access. Further observation revealed the hallway had no resident or resident representative traffic. Observation throughout the facility on 07/14/2026 at 12:10 pm, 2:00 pm, and 3:50 pm revealed there was no poster containing the Ombudsman contact information anywhere in the building other than the posted sign at the main entrance. During an interview at the Resident Council meeting on 07/15/2026 at 10:00 AM it was revealed when asking the council residents R15, R26, R28, R30, R4, and R38 that the residents were unaware of any posted information in the facility related to the Ombudsman or how to contact them. In addition, the residents did not know what an Ombudsman was or what purpose they served.During an interview with the Ombudsman via email on 07/16/2026 at 2:42 PM, she stated her last visit to the facility was on April 23, 2026. The Ombudsman stated she believed to have observed her Ombudsman poster displayed in the front lobby. The Ombudsman added, while this location provided visibility to visitors, it wasn't the most accessible location for residents. The Ombudsman stated the facility would consider placing additional posters in resident areas throughout the building, as many other facilities did, to ensure residents had easier access to Ombudsman contact information. The Ombudsman stated she mailed three additional posters to the facility for placement throughout the facility.During an interview with the Social Services and Activities Director on 07/16/2026 at 3:03 PM, she stated the Ombudsman contact information poster was in the resident television room. After she realized the poster was missing from this location, she stated more than likely a resident tore it from the wall. She stated she had three poster signs coming in the mail this week from the Ombudsman.During an interview with the DON on 07/16/2026 at 3:16 PM, it was revealed she was aware the Ombudsman information was required to be posted and accessible to all residents and resident representatives but did not state who was responsible. During an interview with the Administrator on 07/16/2026 at 3:27 PM, it was revealed she was aware of the missing Ombudsman poster in the residential area of the facility. She stated a letter was posted in place of the poster until the posters arrived in the mail from the Ombudsman.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food items were not dated at the time of storage. Food that had been opened were not covered and/or sealed to prevent contamination. The deficiency had the potential to affect 47 of the facility's 47 residents who consumed food from the kitchen. The findings include: Review of the facility's undated policy titled, Dry Food Storage, revealed dry food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. Dry food products should be labeled and dated when received. All leftovers were dated with the open date and stored accordingly ensuring that food was covered completely in the original box to prevent air exposure. Review of the facility's undated policy titled, Refrigerated Food Storage, revealed refrigerated food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. All refrigerated products should be labeled indicating product name and dated when product was received, and dated when product was opened. Food should be covered completely in the original box to prevent air exposure. Review of the facility's undated policy titled, Frozen Food Storage, revealed refrigerated food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. All frozen products should be labeled indicating product name and dated when product was received, and dated when product was opened. Food should be covered completely in the original box to prevent air exposure. a. Observation of Freezer 2, on 06/23/2025 at 10:25 AM, revealed sausage patties, pancakes, egg omelets, and biscuits were in their original container/box with flaps opened, and the food items were not covered in the plastic bag and was not dated potentially exposing the foods to air contaminants. Continued observation revealed sausage links out of the original container/box without a label and was undated. Additionally, three bags of diced celery and one bag of green beans were opened and placed into a plastic storage bag but had not been dated. b. Observation of Refrigerator 3, on 06/23/2025 at 10:40 AM, revealed a large clear bag of shredded cheddar cheese out of the original container/box with no open date or expiration date. In an interview with Dietary Aide 1, on 06/24/2025 at 2:00 PM, she stated her general duties included distributing food/snack carts on the units, preparing drinks and desserts in the kitchen, and then passing drinks and desserts during meal times for the dining room. She stated she was also responsible for putting away stock when delivered, and those food items were dated with a received by date before being stored. She stated she was aware that refrigerated and freezer food items stored in their original container / box with an inner plastic bag was tied or sealed and the outer flaps on the box was closed and opened by date was included. She further stated if staff had not followed food safety guidelines to prevent freezer burn and/or contamination, food could be ruined and potentially make residents sick. Additionally, she stated all dietary staff should be checking labels and dates and ensuring food items were sealed and covered, noting she would discard any food items that were stored and undated as there was no certain way to know when it had been opened. In an interview with Dietary Aide2, on 06/24/2025 at 2:10 PM, she stated she had worked in the facility for eleven years. She stated she had generally washed dishes but had helped where needed. She stated any food items that were received would be dated with the received date before being stored. She stated that food items that were left over from the steam table the cook would generally store those items. She stated if she was storing leftovers they would be covered, labeled and dated to ensure it was used within the appropriate time frame. She stated if she had stored any food items in its original container/box in the refrigerator or freezer that had previously been opened, the plastic bag would be covered and the box flaps would be closed and an open date would be marked. Food in the freezer that was not sealed could be freezer burned and would not be suitable for the resident because it would not taste good and would not be safe to serve. She stated any food items in the refrigerator that had been placed in a container or storage bag required a label, the open date and should be covered to prevent contamination. She stated if she found any food items without a date that item would be discarded because no one would know when it was opened or when it should be discarded and she would never serve that food to the residents. In an interview with Dietary Manager (DM), on 06/24/25 at 2:22 PM, she stated worked at the facility for thirty years and started out as a cook then moved into management later on. She stated the dietary aides were given a handbook, and they had access to a policy handbook in the kitchen to refer to if needed. She stated they would have new hires train with a preceptor, then they will get official orientation from the Registered Dietician. The RD instructed on allergies, handwashing, food storage, temps, etc. and were completed monthly. The RD had instructed on the International Dysphagia Diet Standardization Initiative (IDDSI) diet which was used to determine meal textures and consistencies. She stated all dietary staff were responsible for the food storage and labeling. She stated she expected staff to store the food items the proper way, if they are storing leftovers in containers to use small containers, label and date correctly. She stated if the food item was opened, it should be labeled with an opened and expiration date. She stated when new stock was received it had been rotated moving the older products to the front and the new to the back. She further stated food items that were not properly stored and labeled would potentially need to be discarded. Additionally, resident outcomes if the food items had been stored for a long period of time but not dated, may cause sickness for anyone but noted staff were aware not to use undated foods in the facility because the residents could potentially get sick and that was not acceptable. In an interview with the Administrator, on 06/25/2025 at 10:00 AM, she stated her expectations for dietary staff members were to follow the policies and procedures of the facility and guidelines set forth by the Registered Dietitian which were in compliance with the Food and Drug Administration (FDA) food service code and Center for Medicare & Medicaid Services (CMS) regulations. She stated all dietary staff were responsible for the foods stored in the pantry, refrigerator, or freezer to be covered, labeled, and dated properly. Additionally, she stated it was important for dietary staff to follow food safety guidelines in order to avoid foodborne illness noting resident safety and satisfaction was among the facility and staff's greatest concern.

Based on interview, record review, review of the facility's policy, and review of the facility reported incident, it was determined the facility failed to have an effective system to ensure residents were free from abuse for two (2) of fifteen (15) residents; Resident #1 and Resident #2. Review of the medical records revealed Resident #1 and Resident #2 had been assessed by the facility to have low Brief Interview for Mental Status (BIMS) scores, indicating cognitive impairment. Resident #1 had a Power of Attorney and Resident #2 had a legal State Guardian for decisions making purposes. Both residents were assessed by the facility to have a history of sexual inappropriate behaviors and were able to self-mobilize. Further, neither resident was assessed to have capacity to consent. On 05/17/2021, Certified Nursing Assistant (CNA) #6 observed Resident #1 in Resident #2's room. Resident #2 had his/her pants and underwear pulled down exposing the genital area and Resident #1 was observed with his/her hands on Resident #2's genital area. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/24/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/24/2021. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021, alleging removal of the Immediate Jeopardy on 09/28/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 09/28/2021, as alleged, prior to exit on 10/07/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed each resident should be afforded Resident Rights, including the right to be free from verbal, sexual, physical, and mental abuse. Per policy, there were seven (7) components that served as a foundation to uphold Resident Rights to be free from abuse: screening, training, prevention, identification, investigating, protection and reporting/response. Additionally, if a resident to resident incident occurred, the resident safety and protection would be assured. Continued review of the policy revealed an investigation would be performed to determine if abuse occurred; a thorough assessment would be completed for the resident(s) and the Responsible Party/Guardian, Attending Physician, the Department of Community Based Services (DCBS) and the Division of Long Term Care would be notified within two (2) hours. Further if the allegation was verified, appropriate corrective action would be taken. Additional review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed the facility mandated that the right of individuals to be protected as outlined in the state and federal regulation and staff were responsible for the health, safety and welfare of all residents. Per policy, abuse, including sexual abuse, was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; Willful was define as deliberate action, not that the individual intended to inflict injury or harm; and Sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with residents. Individuals subject to abuse had the right to be immediately examined by their physician. Further, allegations would be thoroughly investigated by the Abuse Coordinator, Administrator or designee. An Incident Report would be completed documenting the findings. Continued review revealed the Administrator or designee would take prompt action to protect the individuals. A written report of the investigation would be prepared by the Administrator or designee and completed within five (5) working days of the incident. Review of the facility's policy titled, Determination of Mental Capacity for Decision Making, undated, revealed the purpose was to ascertain if a resident had the mental capacity to express themselves. Per policy, Capacity was defined as the most basic level means that a resident had the ability to understand potential consequences and choose a course of action for a given situation. Additionally, resident who were deemed as moderately impaired or cognitively intact, had the capacity to make decisions including, but not limited to, decisions related to care, treatment, safety and autonomy. Continued review revealed upon admission, quarterly and with significant change, mental capacity was reviewed or determined by the Social Services Director. Referring resources, the residents, and their responsible party collaborated information regarding prior determinations such as guardianship, power of attorney (POA), hospital records and other documentation of mental status. The facility determined the type of decisions that must be made by legal responsible parties and those the resident could make according to the assessment of mental capacity, legal requirements and prior determination. Further, residents were required to complete a Brief Interview of Mental Status (BIMS) as part of the admission assessment, quarterly review and with any significant change. Resident who scored zero (0) to seven (7) indicated severe cognitive impairment and would not be considered able to make decisions; therefore, the resident representative had legal authority to address decision making in areas of concern and the facility would respect the representatives decision. 1. Review of Resident #1's medical record revealed the facility admitted the resident, on 09/08/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #1's medical record revealed the resident had a POA. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/21/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision of one (1) staff for transfers, ambulation and locomotion with a walker Review of Resident #1's Comprehensive Care Plan (CCP), dated 01/02/2019, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e. inappropriate touching or comments to female staff related to dementia with behaviors). The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; medicate as ordered; offer diversional activity; state to the resident stop sexual misconduct while immediately distancing resident to prevent harm from aggression, verbal praise the residents non-violent problem solving behaviors; and verbally confront the wrong doing or breech of another's personal rights and request future restraint/cessation of behavior, verbally praise compliance. Further review of Resident #1's CCP, dated 01/20/2021, revealed the resident had impaired cognition related to Alzheimer's Dementia and Panic Disorder. The goal was the resident would not show decline in cognitive function daily. Continued review revealed interventions that included but were not limited to: reduce distractions and negative environmental stimulus as much as possible; offer simple choices allowing sufficient time for decision making; allow the resident to discuss feelings or anger/powerlessness/frustration as needed. Review of Resident #1's Progress Note, dated 03/08/2021 at 3:07 PM, written by Registered Nurse (RN) #2, revealed the resident was attempting to touch peers (other residents) without permission. Further, the Note stated the resident was redirected away from area with frequent checks. However, there was no documented evidence the facility notified the POA or attending Physician. Review of Resident #1's Progress Note, dated 03/24/2021 at 2:14 PM, written by RN #2, revealed the resident was in the television room a few times throughout the day; one (1) time he/she required redirection due to reaching for female peer (resident). Additionally, the resident was reminded about respecting space and Resident #1 left the television area. Review of Resident #1's Progress Note, dated 05/17/2021 at 4:00 PM, written by the Director of Nursing (DON), revealed the resident was involved in resident contact with another peer (resident). Additionally, no injury was noted and the resident and peer (resident) were immediately separated. Further, the Medical Director (MD) and POA were notified. Additional review of Resident #1's Progress Note, dated 05/17/2021 at 4:30 PM, written by the DON, revealed the resident remained with staff until his/her room change was completed. Review of fifteen (15) Minute Checks , dated 05/17/2021 revealed on 05/17/2021 at 4:00 PM, Resident #1 was on 1:1 supervision until 4:30 PM; thirty (30) minutes. There was no further documented evidence of increased supervision for Resident #1. Interview with Resident #1, on 09/21/2021 at 11:30 AM, revealed the resident stated his/her name and further stated he/she was doing alright. Additionally, the resident, stated he/she got along with everyone at the facility and was treated well. Further, the resident stated he/she did not recall an incident involving Resident #2 on 05/17/2021. 2. Review of Resident #2's medical record revealed the facility admitted the resident, on 03/04/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #2's medical record revealed a court ordered full time/permanent State Guardian was appointed to Resident #2 for medical and financial affairs, on 09/30/2019. Review of Resident #2's Quarterly MDS Assessment, dated 02/02/2021, revealed the facility assessed the resident as having a BIMS score of four (4) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision to limited assistance of one (1) staff for transfers, ambulation and locomotion with a wheelchair. Review of Resident #2's CCP, dated 03/05/2020, revealed the resident had impaired cognition related to Alzheimer's Dementia. The goal was the resident would be able to make needs known daily. Continued review revealed interventions that included but were not limited to: allow time for the resident to express self, do no rush, anticipate needs; allow the resident to express feelings of anger/powerlessness and frustration; avoid commands like don't and no; offer simple choices; and reduce distractions and negative environment. Continued review of Resident #2's CCP, dated 09/28/2020, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e. inappropriate sexual comments) related to Dementia with behaviors. The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; and offer diversional activities. Additionally the CCP was revised on 05/13/2021, to include exposing genitals as an example of inappropriate/disruptive behaviors. Further review of Resident #2's CCP, dated 05/14/2021, revealed the resident exhibited social inappropriate behavior as evidence by masturbating in non-private areas. The intervention was to redirect/assist the resident to a room and reiterate the need for privacy (close door, draw curtain) when performing self-pleasure. Review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed On 05/13/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior not directed at other in the television room. Staff redirected the resident to his/her room, closed the curtain and door. Review of Resident #2's Progress Note, dated 05/13/2021 at 7:05 AM, written by the DON, revealed the resident was observed in the television room and had removed his/her brief exposing the peri-area. Additionally, the resident was redirected and assisted with dressing. Continued review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on 05/14/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior; hunching in wheelchair, in the television room. Staff redirected the resident to his/her room. Additional review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on 05/15/2021 and 05/16/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behaviors. Staff provided verbal cues. Review of Resident #2's Progress Note, dated 05/17/2021 at 4:00 PM, written by the DON, revealed the resident was involved in resident contact with another peer (resident). Additionally, no distress was noted and the resident and peer (resident) were immediately separated. Further, the Medical Director (MD) and POA were aware. Review of the facility's Initial Allegation Report and Investigation, which was e-mailed to the Office of Inspector General (OIG- State Survey Agency) on 05/17/2021 at 4:20 PM, signed by the Administrator, revealed a resident to resident incident or allegation had occurred between Resident #1 and Resident #2. The Legal Representative, the Physician, Adult Protective Services (APS), and OIG were notified of the alleged incident on 05/17/2021 at 4:20 PM. Per the report, review of the resident's history, revealed Resident #1 was diagnosed with Heterosexual Behavior, Alzheimer's Disease, Panic Disorder, history of Alcohol Abuse and had a BIMS score (Brief Interview of Mental Status) score of six (6). Per Report, Resident #2 was diagnosed with Alzheimer's Disease, Dementia, Altered Mental Status, and had a BIMS score of four (4). Review of the Description of Allegation or Incident, revealed, Resident #1 was observed in the room of Resident #2 with his/her hand placed on Resident #2's privates as both sat in their wheelchairs. Further review revealed Actions taken to protect resident(s) included immediate separation and assessment, with no injury noted. Resident #1 was placed on 1:1 (one-to-one) supervision and then moved to a different location, on a hallway away from Resident #2. Review of the facility's Five (5) day Investigation, dated 05/20/2021, signed by the Administrator, revealed neither Resident #1 or Resident #2 could provide information. Per the Investigation Report, employee interview, Certified Nursing Assistant (CNA) # 6, revealed she walked into the room of Resident #2 and noted him/her to be seated in a wheelchair with his/her brief off and Resident #1 had his/her hands on Resident #2's private area. She immediately separated the residents. However there was no further documented evidence of other interviews. Additional Findings of the Investigation revealed both residents were confused; Resident #1 with a BIMS score of six (6) and Resident #2 with a BIMS score of four (4). Resident #2 was care planed for self-manipulation and had been noted to be doing that more frequently in the last several days, not in private. Continued review of the Investigation revealed a conclusions, that it was believed Resident #2 left his/her door open and Resident #1 attracted to the situation. Further the Investigation stated the residents were separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Legal Representative's and the Physicians were notified. The Root Cause established by the facility was impaired cognition. Review of facility staffing assignments, dated 05/17/2021, revealed CNA #6, CNA #9, CNA, #10 and RN #1 were assigned to the Arcadia Unit on 05/17/2021 6:00 AM/6:00 PM shift. However, there was no documented evidence of statements from CNA #9, CNA #10 or RN #1, related to the allegation of sexual abuse between Resident #1 and Resident #2, on 05/17/2021 Review of CNA #6's witness statement, dated 05/17/2021, (CNA #6 was assigned to Resident #1 and Resident #2's hallways {Arcadia} on 05/17/2021), revealed she walked into Resident #2's room and the resident was in his/her wheelchair with their pants and brief pulled down. Resident #1's hand was on Resident #2's genital area. She immediately separated the residents and told the charge nurse. Interview with Resident #1, on 09/21/2021 at 11:20 AM, revealed the resident stated his/her name and further stated he/she was doing well. Additionally, the resident, stated he/she got along with everyone at the facility and the facility staff and treated him/her good. Further, the resident stated he/she did not recall an incident involving Resident #1 on 05/17/2021. Interview with CNA #6, on 09/22/2021 at 1:00 PM, revealed Resident #1 was confused and able to self-ambulate with a rolling walker. Continued interview revealed Resident #1 was known to attempt to touch female staff and residents; staff tried to keep confused residents away from Resident #1 because of this behavior. Additionally, Resident #2 was confused and able to self-propel in a wheelchair. Continued interview revealed Resident #2 would masturbate and staff provided redirection and privacy when he/she was masturbating. Per interview, on 05/17/2021, she worked on Arcadia Unit with CNA #9, CNA #10 and Registered Nurse (RN) #1. On 05/17/2021 at approximately 3:00 PM, she was assisting a resident up the hallway to the shower room and noted Resident #1 in his/her room in bed. Continued interview revealed, two (2) doors up from Resident #1's room, Resident #2 was noted sitting in a wheelchair in his/her room. Both residents were fully dressed. CNA #6 entered the shower room (directly across the hallway from Resident #2's room) with another resident and remained in the shower room for ten (10) minutes. Per interview, when she was exiting the shower room, she saw Resident #1 standing in front of Resident #2 with a rolling walker, in Resident #2's room. Resident #2 was seated in his/her wheelchair with his/her brief and pants was pulled down to the knees with his/her legs spread. Resident #1's hands were in between Resident #2's legs touching his/her genital area. Further, she told the residents to stop; told Resident #2 to pull up his/her pants and closed the room door, and she escorted Resident #1 to the nurses station and told RN #1 what she had walked in on. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed Resident #1 was confused and required supervision with Activities for Daily Living (ADL), including self-ambulation with his/her walker. Continued interview revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #2 was confused and required assistance with ADLs; Resident #2 was able to self-propel in his/her wheelchair. Continued interview revealed Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview revealed, after review of Resident #1's medical record, on 05/17/2021, RN #1 was working but the alleged sexual abuse between Resident #1 and Resident #2 was reported to the Director of Nursing (DON) and not RN #1. Continued interview revealed she completed Skin Assessments per the DON's directed on Resident #1 and Resident #2. Per review of the medical record, RN #1 stated Resident #1's room was changed and Resident #2 was placed on fifteen (15) minute checks. Further, she was not aware if staff on Arcadia Unit were interviewed on 05/17/2021 (she did not provide a statement) or if residents on Arcadia Unit were assessed or interviewed. Interview with the Social Services Director (SSD), on 09/22/2021 at 5:06 PM, revealed she was the facility's Abuse Coordinator, and worked with the Administrator and nursing team to investigate abuse. Continued interview revealed the Administrator lead abuse investigations in the facility and as the Social Worker, she typically interviewed residents and assessed their psychosocial well-being during investigations. Additionally, she monitored Mood and Behavior Patterns flowsheet daily to establish patterns and interventions to meet resident needs. Per interview, after review she would make necessary revisions to the Care plan. Further, resident's capacity to consent was assessed on admission, quarterly, annually, and with significant change with the BIMS assessment. Continued interview revealed residents with moderately to intact cognition, or with BIMS score eight (8) and above could make their own decisions, unless they had a legal guardian. Per interview, the IDT would be involved and the physician should be involved when determining resident capacity to consent. Continued interview with the SSD, on 09/22/2021 at 5:06 PM, revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However she had never witnessed the behavior and had not seen the behavior documented for a long time. Additionally, Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However the IDT determine redirection was effective for the resident's increased frequency and change in behaviors on 05/13/2021 through 05/16/2021. Further, on 05/17/2021, she was informed by the DON of the alleged sexual abuse between Resident #1 and Resident #2; when she went to talk to the residents about the incident neither resident recalled the incident and showed no negative psychosocial outcomes. State Survey Agency (SSA) attempted to contact CNA #10, on 09/24/2021 at 12:14 PM. Telephone interview with CNA #9, on 09/24/2021 at 2:30 PM, revealed he was working on the Arcadia Unit, on 05/17/2021. Continued interview, revealed on 05/17/2021, when the sexual abuse occurred he was on the Arcadia Unit, however he was in another resident's room providing care. Additionally, he did recall CNA #6 talking about the sexual abuse between two (2) residents when CNA #10 came back from lunch. Further, he did not provide a statement on 05/17/2021. Interview with the DON, on 09/23/2021 at 1:05 PM, revealed Resident #2 had intensified inappropriate sexual behaviors including masturbating in non-private areas and vulgar comments directed towards others since 05/13/2021; however, the Interdisciplinary Team (IDT) (which included the Administrator, Minimum Data Set {MDS} Nurse, Therapy, Social Services, Unit Managers {UM}, and the Assistant Director of Nursing {ADON}), reviewed the behaviors on 05/14/2021 and 05/17/2021 and determined redirection alone was an effective intervention for the behaviors. Per interview, Resident #1 had inappropriate sexual behaviors directed towards other; however prior to the alleged sexual abuse on 05/17/2021 the resident had never wandered into other's rooms. Additionally, on 05/17/2021 at approximately 4:00 PM, she received a call from RN #1, related to resident to resident incident involving inappropriate sexual behaviors between Resident #1 and Resident #2. Per interview, she walked to the Arcadia Unit Nursing Station, Resident #1 was in his/her room with CNA #10 and Resident #2 was in his/her room on fifteen (15) minute checks; CNA #6 told her she walked out of the shower room, on the Arcadia Unit, and observed Resident #1 in Resident #2's room with his/her hands on Resident #2's private area between his/her legs. Resident #2's pants and brief were pulled down and the Resident's legs were spread. Additional interview revealed the DON had saw Resident #2 in the television room fifteen (15) minutes prior to the alleged sexual abuse, on 05/17/2021. Continued interview revealed an unknown staff had reported to the DON, early in the day (time unknown) on 05/17/2021, Resident #1 had been in the television room exhibiting inappropriate sexual behaviors, vulgar comments directed towards others. Per the DON, she was not aware if Resident #1 and Resident #2 were in the television room at the same time. Further interview revealed the DON initiated an investigation of the allegation of sexual abuse and directed RN #1 to complete Skin Assessment on Resident #1 and Resident #2. Continued interview revealed, no further Skin Assessments on other resident's or interviews with staff or residents was completed because the she had saw Resident #1 in the television room fifteen (15) minutes prior to the allegation of sexual abuse and CNA #6 had seen Resident #1 ten (10) minutes prior to the incident so there was only a small window of time the resident was not in line of sight of staff. Further, the DON did not increase supervision of Resident #1 after his/her room change to another Unit because she believed Resident #2 instigated the incident and he/she was on fifteen (15) minute checks. The DON stated the allegation of sexual abuse between Resident #1 and Resident #2 was not abuse because even though cognitively both resident could not consent due to impairments, they wanted the behaviors to happen and it was not a forceful incident. Although it was not an acceptable incident between the two (2) residents, it was a mutual agreement and no harm occurred. Telephone interview with Resident #1's spouse and POA, on 09/24/2021 at 11:41 AM, revealed Resident #1 had transferred to the facility from another Skilled Nursing Facility after increased behaviors and advances directed towards female residents such as patting them on the bottoms and other residents had complained and were concerned. Additionally, she had never been asked by the facility about consent for Resident #1 to engage in sexual behaviors at the facility. However, if asked, consent would not been given for the resident to engage in sexual acts because he/she could not make the best decisions about life and care, and he/she was still married. Per interview, Resident #1 had a childlike mind due to being dropped as a baby and also had alcohol induced dementia. Continued interview revealed Resident #1 had been accused of sexual abuse towards a minor many years ago. Further, the facility had informed her, on 05/17/2021 that Resident #1 was involved with a resident however specifics were not provided. Interview with Resident #1 and Resident #2's Physician, on 09/24/2021 12:20 PM, revealed sexual acts between resident's required capacity to consent and residents with impaired cognition would need to be assessed for capacity and their responsible party and himself should be involved. Further residents with sexual behaviors directed towards others required increased supervision, which should continue after a sexual abuse incident for all residents involved, to prevent further abuse. Interview with the Medical Director, on 09/24/2021 at 6:40 PM, revealed residents with dementia should be assessed by the facility for capacity to consent to sexual relationships. Additionally, capacity to consent should be determined by the facility, on an individual basis, including review of the advanced directives. Further, she had not been involved in the determinations of capacity to consent for Resident #1 or Resident #2. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed the DON informed her on 05/17/2021 between 1:00 PM and 4:00 PM that Resident #1 had his/her hand on Resident #2's privates. Additional interview revealed the Administrator initiated an abuse investigation, on 05/17/2020, following the facility's policy and procedures. Continued interview revealed the DON interviewed Resident #1 and Resident #2; however she did not directed the nursing department to complete skin assessments and resident interviews for residents on the Arcadia Unit; statements where obtained from CNA #6 because she was the only staff member who witnessed the event. Further, she stated it was her responsibility, as the Administrator, to ensure all policies were followed to ensure systems were in place to protect all residents from abuse. Per interview, the facility concluded based on their investigation the root cause of the incident was confusion. Both residents involved had impaired cognitive status; the residents were not aware and did not have capacity to consent to what they were doing and there was no injury, therefore abuse did not occur. Telephone interview with the State Guardian, on 09/28/2021 at 3:45 PM, revealed Resident #2 was totally disabled and adjudicated by the court system in November of 2018. The resident was determined unable to make decisions about his/her personal health or finances. Continued interview revealed at that time Guardianship was initiated, the resident was living in the community with his/her son and the son had passed away in the home and the resident did not know it until a neighbor discovered it. Additionally, she had not been approached at any time since admission to the facility about the resident's capacity to consent. Per interview, Guardianship typically did not give consent/permission for sexual behaviors and asked facility's to ensure residents were protected and not victimized or abused due to their impaired cognition. Further, she had not been informed of changes/increased sexual behavior starting on 05/13/2021; however she would expected to be notified of changes in the residents conditions. Continued interview revealed she had been informed by the DON on 05/17/2021 that Resident #2 had initiated and made sexual advanced towards another resident. However, she had not been informed of the specifics or the investigation. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021 that alleged removal of the Immediate Jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of pri [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented. On 05/17/2021, Resident #1 touched Resident #2's genital area. Additionally, on 05/18/2021, Resident #3, kissed Resident #1 on the lips. However, the facility did not implement their policy for protecting residents, thoroughly investigating allegations of sexual abuse and reporting. 1. Review of Resident #1 and Resident #2's Incident Reports, dated 05/17/2021 at 4:00 PM, revealed Resident #1 was observed in Resident #2's room with his/her hands resting on Resident #1's peritoneal area. Resident #1's clothing was pulled down. The facility initiated an investigation on 05/17/2021; however, review of the investigation, dated 05/20/2021 revealed no documented evidence the facility implemented the facility's abuse policy related to completing a thorough investigation or protecting residents from abuse. There was no documented evidence Resident #1 was provided increased supervision, after 05/17/2021 at 4:30 PM, providing the potential for further abuse. Further, there was no documented evidence statements for staff assigned to Resident #1 and Resident #2 on 05/17/2021 were obtained. 2. Review of Resident #3's Incident Report, dated 05/18/2021 at 7:15 AM revealed the resident rolled up to Resident #1 in the television room and kissed him/her on the lips. The facility initiated an investigation on 05/18/2021; however, review of the investigation, dated 05/18/2021 revealed no documented evidence the facility implemented the facility's abuse policy related to completing a thorough investigation. There was no documented evidence of interview with residents in the facility for the investigation on 05/18/2021. Further, review of the email confirmation of the Allegation Report and Investigation, dated 05/18/2021, revealed the time sent was 10:01 AM; approximately three (3) hours after the allegation of abuse. The facility's failure to implement its policies and procedures regarding reporting, investigating, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/24/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/24/2021. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021, alleging removal of the Immediate Jeopardy on 09/28/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 09/28/2021, as alleged, prior to exit on 10/07/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation, reviewed on 07/07/2020, revealed that three (3) of the seven (7) components to ensure residents were free from abuse included investigating, protection, and reporting/response. Continued review revealed if a resident-to-resident incident occurred, the resident safety and protection would be assured. Additional review of the policy revealed an investigation would be performed to determine if abuse occurred; a thorough assessment would be completed for the resident(s) and the Responsible Party/Guardian, Attending Physician, the Department of Community Based Services (DCBS) and the Division of Long-Term Care would be notified within two (2) hours. Further if the allegation was verified, appropriate corrective action would be taken. Additional review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed the facility mandated that the right of individuals to be protected as outlines in the state and federal regulation and staff were responsible for the health, safety, and welfare of all residents. Per policy, abuse, including sexual abuse, was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; willful was define as deliberate action, not that the individual intended to inflict injury or harm; and sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with residents. Further, allegations would be thoroughly investigated by the Abuse Coordinator, Administrator, or designee. An Incident Report would be completed documenting the findings. Continued review revealed the Administrator or designee would take prompt action to protect the individuals. A written report of the investigation would be prepared by the Administrator or designee and completed within five (5) working days of the incident. Review of the facility policy, Investigation, undated, revealed all incidents that occurred in the facility required a thorough investigation and accurate documentation to evaluate and determine why incidents occurred, take corrective action to curtain the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. Additionally, the Charge Nurse or Department Head on duty at the time of the incident would conduct the investigation. Per policy, a prompt response to identified incidents was imperative to obtain accurate date and to treat ill effects experienced by residents from the alleged incident and to safeguard residents from further incident. Continued review revealed a thorough, complete investigation was intended to allow the facility to identify and document who was involved in the incident and establish the how, what, when, where, who and why the incident happened. The investigation should focus on whether the allegation was substantiated or unsubstantiated. Further the investigation required data collection from those who were involved, who may have information related to the incident and what the chronological order of action leading up to the incident, what the witness saw, what information other staff member knew, what was known about those involved in the incident. Continued review revealed the alleged victim and suspect, as well as caregivers in the immediate area should be interviewed. 1. Review of the facility's Initial Allegation Report and Investigation, which was e-mailed to the Office of Inspector General (OIG- State Survey Agency), on 05/17/2021 at 4:20 PM, signed by the Administrator, revealed a resident-to-resident incident or allegation had occurred between Resident #1 and Resident #2. Further review revealed, on the same date and time, the Legal Representative, the Physician, Adult Protective Services (APS), and OIG were notified of the alleged incident. Review of the Description of Allegation or Incident, revealed, Resident #1 was observed in the room of Resident #2 with his/her hand placed on Resident #2's privates as both sat in their wheelchairs. Review of the facility's Five (5) day Investigation, dated 05/20/2021, signed by the Administrator, revealed per investigation, an interview with Resident #1 nor Resident #2 could provide information related to the resident-to-resident allegation or incident. Additionally, interview with an employee, Certified Nursing Assistant (CNA) # 6, revealed she walked into the room of Resident #2 and noted him/her to be seated in a wheelchair with his/her brief off and Resident #1 had his/her hands on Resident #2's private area. Further the Investigation stated the residents were separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's schedule revealed CNA #9, CNA #10, and Registered Nurse (RN) #1 were assigned to Resident #1 and Resident #2 on 05/17/2021 6:00 AM/6:00 PM shift; however, there was no documented evidence the facility obtained a statement from CNA #9, CNA #10, and RN #1 related to the allegation of abuse. Review of the facility's Brief Interview of Mental Status (BIMS) scores for all residents revealed sixteen (16) residents had BIMS scores of eight (8) or above, indicating they were interviewable; however, there was no documented evidence of interviews with those residents in the facility related to abuse or Skin Assessment for the thirty-four (34) {excluding Resident #1 and Resident #2} who were not interviewable. According to the Investigation Report, the facility determined Resident #1 and Resident #2 had no injuries or recollection of the incident which occurred and established the root cause as impaired cognition. Further, according to interviews with the Director of Nursing (DON), on 09/23/2021 at 1:05 PM and Administrator, on 09/24/2021 at 5:00 PM, the facility did not substantiate the alleged sexual abuse based on the available facts and information. Per interviews, both residents were confused, and it was believed since Resident #2 had more frequent and intensified inappropriate sexual behaviors starting on 05/13/2021, he/she had invited Resident #1 to engage in resident-to-resident sexual behaviors on 05/17/2021. Further, the residents had no injuries noted and when both residents were asked about the incident, neither could recall the occurrence. Interview with CNA #6, on 09/22/2021 at 1:00 PM, revealed she worked on Arcadia Unit on 05/17/2021. Per interview, on 05/17/2021 at approximately 3:00 PM, she saw Resident #1 in his/her room in bed and Resident #2 was sitting in a wheelchair in his/her room, on the same hallways only a couple doors apart. Both residents were fully dressed. Additionally, CNA #6 was in the shower room (directly across the hallway from Resident #2's room) with another resident for ten (10) minutes. Per interview, when she was exiting the shower room, she saw Resident #1 standing in front of Resident #2 with a rolling walker, in Resident #2's room. Resident #2 was seated in his/her wheelchair with his/her brief and pants was pulled down to the knees with his/her legs spread. Resident #1's hands were in between Resident #2's legs touching his/her genital area. Further, she told the residents to stop; told Resident #2 to pull up his/her pants and closed the room door, and she escorted Resident #1 to the nurse's station and told RN #1 what she had witnessed. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed she had worked on the Arcadia Unit on 05/17/2021 from 6:00 AM/6:00 PM shift. Per interview, she recalled a few months ago charting on Resident #1 related to the resident had touched another resident when he/she rolled up to the resident; however, she did not recall that the incident between Resident #1 and Resident #2 occurred on that date or that it was reported to her by CNA #6. Additionally, after review of Resident #1's medical record, on 05/17/2021, RN #1 was working but the alleged sexual abuse between Resident #1 and Resident #2 was reported to the DON and not RN #1. Continued interview revealed the DON directed her to completed Skin Assessments on Resident #1 and Resident #2, only. Per review of the medical record, RN #1 stated Resident #1's room was changed, and Resident #2 was placed on fifteen (15) minute checks, which were initiated by the DON. Further, she was not aware if staff on Arcadia Unit were interviewed on 05/17/2021 or if residents on Arcadia Unit were assessed or interviewed as part of the investigation. She did not provide a statement for the investigation on 05/17/2021. Interview with the DON, on 09/23/2021 at 1:05 PM, revealed on 05/17/2021 at approximately 4:00 PM, she received a call from RN #1, related to a resident-to-resident incident involving inappropriate sexual behaviors between Resident #1 and Resident #2. Per interview, she walked to the Arcadia Unit Nursing Station, where CNA #6 told her she had observed Resident #1 in Resident #2's room with his/her hands on Resident #2's private area between his/her legs, and that Resident #2's pants and brief were pulled down and the Resident's legs were spread. Continued interview revealed Resident #1 was in his/her room with CNA #10 on one (1) on one (1) supervision and Resident #2 was in his/her room on fifteen (15) minute checks. Additionally, she initiated an investigation of the allegation of sexual abuse and directed RN #1 to complete Skin Assessment on Resident #1 and Resident #2 only because she had seen Resident #1 in the television room fifteen (15) minutes prior to the allegation of sexual abuse and CNA #6 had seen Resident #1 ten (10) minutes prior to the incident so there was only a small window of time the resident was not in line of sight of staff. Continued interview revealed, no further Skin Assessments on other resident's or interviews with staff or residents was completed because the of the small window Resident #1 was not visualized before the alleged sexual abuse. Per interview, no other staff witnessed the alleged abuse. Further, after Resident #1's room change to another Unit she did not increase his/her supervisions because she believed Resident #2 instigated the incident and he/she was on fifteen (15) minute checks; therefore, the residents were protected from potential further abuse. The DON stated the allegation of sexual abuse between Resident #1 and Resident #2 was not abuse because both residents were cognitively impaired but wanted the behaviors to happen and it was not a forceful incident. Although it was not an acceptable incident between the two (2) residents, it was a mutual agreement and no harm had occurred. Per interview, the facility's policy and procedure on abuse were followed and no further abuse occurred. State Survey Agency (SSA) attempted to contact CNA #10, on 09/24/2021 at 12:14 PM. SSA attempted to contact CNA #11, on 09/24/2021 at 12:15 PM. Telephone interview with CNA #9, on 09/24/2021 at 2:30 PM, revealed he did not witness the alleged sexual abuse between Resident #1 and Resident #2 because he was in another resident's room providing care when it occurred. However, he did recall CNA #6 talking about the sexual abuse between the two (2) residents when CNA #10 came back from lunch. Further, he did not provide a statement related to the abuse on 05/17/2021. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed the DON informed her on 05/17/2021 between 1:00 PM and 4:00 PM that Resident #1 had his/her hand on Resident #2's privates. Additional interview revealed the Administrator directed the DON to initiate an abuse investigation, on 05/17/2020, following the facility's policy and procedures. Further interview revealed the DON interviewed Resident #1 and Resident #2; however, the Administrator did not direct the nursing department to complete skin assessments and resident interviews because the incident only involved Resident #1 and Resident #2. Per the Administrator statements were obtained from CNA #6 because she was the only staff member who witnessed the incident. 2. Review of the facility's Initial and Final Allegation Report and Investigation, which was e-mailed to the Office of Inspector General (OIG- State Survey Agency), on 05/18/2021 at 10:01 AM, signed by the Administrator, revealed a resident-to-resident incident or allegation had occurred between Resident #1 and Resident #3. Further review revealed, on the same date and time, the Legal Representative, the Physician, Adult Protective Services (APS), and OIG were notified of the alleged incident. Review of the Description of Allegation or Incident, revealed, Resident #3 was observed in the dining room to roll his/her wheelchair over to Resident #1 and kiss the resident on the lips. Per investigation, an interview with Resident #3 revealed the resident thought he/she was kissing his/her spouse good morning. Additionally, an employee interview, Certified Nursing Assistant (CNA) # 11, revealed she was in the dining room and witnessed Resident #3 roll his/her wheelchair up to Resident #1 and kiss them on the lips. Further the Investigation stated the residents we separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Brief Interview of Mental Status (BIMS) scores for all residents revealed sixteen (16) residents had BIMS scores of eight (8) or above, indicating they were interviewable; however, there was no documented evidence of interviews with those residents in the facility. According to the Investigation Report, the facility determined Resident #1 and Resident #3 had no injuries and Resident #3 thought he/she had kissed their spouse and established the root cause as impaired cognition. Further, according to interviews with the Director of Nursing (DON), on 09/23/2021 at 1:05 PM and Administrator, on 09/24/2021 at 5:00 PM, the facility did not substantiate the alleged sexual abuse based on the available facts and information. Per interviews, both residents were confused, and it was believed Resident #3 thought Resident #1 was his/her spouse. Further, the residents had no injuries noted therefore the incident was not abuse. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed she recalled charting on Resident #3 related to the resident had kissed another resident; however, she did not recall that the incident between Resident #1 and Resident #3 occurred on that date. Additionally, after review of Resident #3's medical record, on 05/18/2021, she had completed Skin Assessments on Resident #1 and Resident #3. Per review of the medical record, RN #1 stated Resident #3 was placed on increased supervision, which was initiated by the DON. Further, she was not aware if residents on Arcadia Unit were assessed or interviewed as part of the investigation. Additional interview with the DON, on 09/23/2021 at 1:05 PM, revealed on 05/18/2021 at approximately 7:00 AM, she was notified by CNA #11 or RN #1, that Resident #3 had rolled up to Resident #1 in the dining room and kissed the resident on the lips. Per interview, she initiated an investigation, and the residents were immediately separated, and Resident #3 was assisted to his/her room with increased supervision. Additionally, she directed RN #1 to assess the two (2) residents involved since it was a witnessed incident. Per interview, the DON, talked to both residents involved and Resident #1 stated he/she did not know what happened and Resident #3 stated he/she kissed their spouse good morning. Continued interview revealed the DON obtained CNA #11's statement because she witnessed the kiss. However, she did not obtain further statements from other staff or residents because it was an isolated event. The DON stated the allegation of sexual abuse between Resident #1 and Resident #3 was not abuse because both residents were cognitively impaired. Further, the facility's policy and procedure on abuse were followed. SSA attempted to contact CNA #11, on 09/24/2021 at 12:15 PM. Additional interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed the DON informed her on 05/18/2021 that Resident #3 had kissed Resident #1 on the lips while in the dining room. Additional interview revealed an investigation of the incident was initiated following the facility's policy and procedure. Per interview, the DON conducted interviews with the residents involved; she did not direct her to interview other residents because it was a witnessed incident. Further, she completed the facility's investigation and reported to the appropriate agencies timely. Further interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed, she stated it was her responsibility, as the Administrator, to ensure all policy(s) were followed to ensure systems were in place to protect all residents from abuse. Per interview, the facility concluded based on their investigation the root cause of both incidents on 05/17/2021 and 05/18/2021 was impaired cognition/confusion. All residents involved had impaired cognitive status; the residents were not aware and did not have capacity to consent to what they were doing and there was no injury, therefore abuse did not occur. The Administrator stated the facility's written policies were implemented related to reporting abuse, investigating abuse, and protecting residents from further potential abuse related to the allegation of abuse for Resident #1, Resident #2, and Resident #3. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021, that alleged removal of the Immediate jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of privacy. On 09/26/2021, the Minimum Data Set (MDS) Coordinators and the DON revised the care plan for Resident #1 to include constant one on one visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #1 was free from abuse. (c) On 09/24/2021, the DON reviewed the care plan for Resident #2 including the provision of privacy for any observed sexual behaviors and that privacy will be assured until the sexual behavior had concluded. On 09/26/2021, the MDS Coordinators and the DON revised the care plan for Resident #2 to include constant visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #2 was free from abuse. 2. (a) The Social Services Director (SSD) interviewed all interviewable residents on 09/24/2021 to solicit for any concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. These interviews were to be completed daily seven days a week by the SSD or assistant. (b) The Administrator mobilized the ReachAlert system, an automated communication system that can contact all staff, residents or their responsible parties by phone text or email, on 09/24/2021 to contact each employee and resident representative to solicit any resident concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. (c) From 09/24/2021 through 09/25/2021, the DON and Charge Nurse completed physical observations including skin assessments of each resident to assure that residents were free from abuse and neglect. 3. (a) On 09/24/2021, the facility secured a long-term care consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. The LTCC provided education to the Administrator on 09/24/2021 and 09/25/2021 regarding the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation. The Administrator completed a post-test on 09/26/2021. The education provided by the LTCC was according to the Abuse Prohibition Policies of the facility. (b) On 09/24/2021, the LTCC started meeting daily with the Administrator to review the practices and outcomes of education provided to the administrator who passed on the education to management staff that included the DON and the SSD. The education included the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation and to provide daily guidance. (c) From 09/24/2021 through 09/27/2021, the SSD and the DON, who were trained by the Administrator, and a charge nurse trained by the DON on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation, provided education to all employees of the facility and agency staff. Freedom from abuse, neglect and exploitation and resident rights was included in the education and according to the facility policies on abuse prevention and implementation of the facility abuse prohibition policies. Each employee received a post-test from 09/24/2021 through 09/27/2021 after receiving the education. Employees and agency staff that were off work and unavailable to work for any reason will receive this education and post-test before returning to work. (d) From 09/24/2021 through 09/26/2021, the MDS Coordinators and the DON completed resident care plan reviews to provide updates, needed revisions and care plan implementation daily to address the assessed needs related to supervision and monitoring to ensure a safe environment and prevent sexual abuse. 4. Beginning on 09/24/2021, the Quality Assurance Committee (QAC) conducted daily meetings seven (7) days per week to review actions taken and compliance with implementation of the abuse policies. The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 09/28/2021 as alleged: 1. (a) Review of the nursing notes for Resident #1 revealed the resident was moved to another room in the facility on a different unit on 05/17/2021. (b) Review of the record for Resident #1 revealed the facility revised the Care Plan on 09/24/2021, 09/26/2021, and 09/27/2021. Interventions included redirection for any observed sexual behaviors, provision of privacy for sexual behaviors, and constant one-on-one visual supervision by staff. Observation of Resident #1 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided for Resident #1. (c) Review of the record for Resident #2 revealed the facility revised the Care Plan on 09/24/2021 and on 09/26/2021. The interventions included provision of privacy for sexual behaviors until the sexual behavior concluded and constant visual observation by staff trained in the abuse prohibition policies of the facility. Observation of Resident #2 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided. 2. (a) Interview with the SSD, on 10/06/2021 at 2:59 PM, revealed she completed interviews with all residents with a BIMS score of 8 or above on 09/24/2021 and has continued the interviews daily since that time. Review of Resident Daily Interviews and Observations log revealed residents of the facility with BIMS of 8 or above were interviewed daily beginning 09/24/2021. No concerns with abuse were identified. (b) Interview with the Administrator, on 10/07/2021 at 11:21 AM, revealed the ReachAlert system was mobilized on 09/24/2021 to solicit concerns from staff and resident representatives. The administrator stated the system was still being utilized daily and there had been no concerns verbalized through the system. Review of the emails printed from the ReachAlert system revealed messages had went out daily since 09/24/2021. (c) Review of Body Audits, dated 09/25/2021, revealed the DON completed skin assessments of each resident on 09/25/2021. Interview with the DON, on 10/07/2021 at 11:21 AM, revealed she had completed the body audits on 09/25/2021 for any signs of abuse or neglect. Further review of the Body Audits revealed no concerns were identified. 3. (a) Interview with the facility's LTCC, on 10/07/2021 at 10:57 AM, revealed she started working with the Administrator on 09/24/2021 providing education regarding abuse. The LTCC stated that the Administrator had completed a post-test on 09/26/2021 regarding the education provided and no concerns were identified. (b) Review of the Administrator Education Log revealed the LTCC had met with the Administrator daily and had provided education related to abuse and neglect on a daily basis since 09/24/2021. The education included prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse allegations, timely assessment and revision of care plans, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse. Further review of the log revealed the Administrator had educated the DON and SSD. (c) Review of the Education Logs revealed from 09/24/2021 through 09/27/2021 all staff who were working or scheduled to work were retrained on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation. Further review of the Education Logs revealed copies of post-tests completed by the staff to ensure the education was effective. Interviews on 10/06/2021 with Housekeeper #14 at 2:30 PM, State Registered Nursing Assistant (SRNA) #9 at 2:50 PM, RN #1 at 3:29 PM, SRNA #6 at 3:55 PM, and SRNA #2 at 4:05 PM and interviews on 10/07/2021 with SRNA #7 at 10:15 AM revealed they had all received abuse education from the administration and the education included the different types of abuse, protection of the resident from further abuse, and immediate reporting of abuse. (d) Review of the Care Plan Audits revealed the MDS coordinators reviewed all resident care plans on 09/26/2021. Interview with RN #1 on 10/06/2021 at 3:29 PM revealed she was one of the MDS coordinators and completed a review of all resident care plans on 09/26/2021 and ensured behavioral interventions were current for each resident. 4. Review of the Quality Assurance (QA) Daily Meeting Logs revealed QA meetings were conducted daily from 09/24/2021 through 10/06/2021. Interview with the Administrator and the DON on 10/07/2021 at 11:21 AM revealed the QA meetings were on going and would continue until compliance was achieved.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to complete a thorough investigation in response to an alleged violation of abuse, allowing for further potential abuse for two (2) of fifteen (15) residents; Residents #1 and Resident #2. On 05/17/2021, Certified Nursing Assistant (CNA) #6 observed Resident #1 in Resident #2's room. Resident #2 had his/her pants and underwear pulled down exposing the genital area and Resident #1 was observed with his/her hands on Resident #2's genital area. The facility initiated an investigation on 05/17/2021; however, review of the investigation, dated 05/20/2021 revealed no documented evidence the facility implemented the facility's abuse policy related to completing a thorough investigation. There was no documented evidence of statements for staff assigned to Resident #1 and Resident #2 on 05/17/2021, and no documented evidence other cognitive residents in the facility were interviewed or skin assessments for residents with cognitive impairments were completed. The facility's failure to have an effective system in place to ensure all allegations of abuse were thoroughly investigated, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/21/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/24/2021. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021, alleging removal of the Immediate Jeopardy on 09/28/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 09/28/2021, as alleged, prior to exit on 10/07/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility policy, Investigation, undated, revealed all incidents that occurred in the facility required a thorough investigation and accurate documentation to evaluate and determine why incidents occurred, take corrective action to curtain the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. Additionally, the Charge Nurse or Department Head on duty at the time of the incident would conduct the investigation. Per policy, a prompt response to identified incidents was imperative to obtain accurate data and to treat ill effects experienced by residents from the alleged incident and to safeguard residents from further incident. Continued review revealed a thorough, complete investigation was intended to allow the facility to identify and document who was involved in the incident and establish the how, what, when, where, who and why the incident happened. The investigation should focus on whether the allegation was substantiated or unsubstantiated. Further the investigation required data collection from those who were involved, who may have information related to the incident and what the chronological order of action leading up to the incident, what the witness saw, what information other staff member knew, what was known about those involved in the incident. Continued review revealed the alleged victim and suspect, as well as caregivers in the immediate area should be interviewed. Review of the facility's policy, Abuse, Neglect, and Exploitation, reviewed on 07/07/2020, revealed that one (1) of the seven (7) components to ensure residents were free from abuse included investigating. Further review of the policy revealed an investigation would be performed to determine if abuse occurred; a thorough assessment would be completed for the resident(s). Additional review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed the facility mandated that the right of individuals to be protected as outlines in the state and federal regulation and staff were responsible for the health, safety, and welfare of all residents. Per policy, abuse, including sexual abuse, was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; willful was define as deliberate action, not that the individual intended to inflict injury or harm; and sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with residents. Further, allegations would be thoroughly investigated by the Abuse Coordinator, Administrator, or designee. An Incident Report would be completed documenting the findings. Continued review revealed the Administrator or designee would take prompt action to protect the individuals. A written report of the investigation would be prepared by the Administrator or designee and completed within five (5) working days of the incident. Review of the facility's Initial Allegation Report and Investigation, which was e-mailed to the Office of Inspector General (OIG- State Survey Agency) on 05/17/2021 at 4:20 PM, signed by the Administrator, revealed a resident-to-resident incident or allegation had occurred between Resident #1 and Resident #2. The Legal Representative, the Physician, Adult Protective Services (APS), and OIG were notified of the alleged incident on 05/17/2021 at 4:20 PM. Further review of the Description of Allegation or Incident, revealed, Resident #1 was observed in the room of Resident #2 with his/her hand placed on Resident #2's privates as both sat in their wheelchairs. Review of Resident #1's interview obtained by the facility, on 05/17/2021, conducted by the DON, revealed he/she did not do anything wrong, Resident #2 asked him/her to come in there. Review of Resident #2's interview obtained by the facility, on 05/17/2021, conducted by the DON, revealed Resident #1 did not do anything wrong; I asked him/her to. It felt good. Review of the facility's Brief Interview of Mental Status (BIMS) scores for all residents revealed sixteen (16) residents had BIMS scores of eight (8) or above, indicating they were interviewable; however, there was no documented evidence of interviews with those residents in the facility related to abuse or Skin Assessment for the thirty-four (34) {excluding Resident #1 and Resident #2} who were not interviewable. Further review revealed there was no documented evidence of statements from other residents related to the allegation of sexual abuse on 05/17/2021. Review of the Five (5) day Investigation, dated 05/20/2021, signed by the Administrator, revealed neither Resident #1 nor Resident #2 could provide information. Per the Investigation Report, employee interview, Certified Nursing Assistant (CNA) # 6, revealed she walked into the room of Resident #2 and noted him/her to be seated in a wheelchair with his/her brief off and Resident #1 had his/her hands on Resident #2's private area. She immediately separated the residents. However, there was no further documented evidence of other interviews with staff or residents in the facility. Further the Investigation stated the Root Cause established by the facility was impaired cognition. Legal Representative's and the Physicians were notified. Review of CNA #6's witness statement, dated 05/17/2021, (CNA #6 was assigned to Resident #1 and Resident #2's hallways {Arcadia} on 05/17/2021), revealed she walked into Resident #2's room and the resident was in his/her wheelchair with their pants and brief pulled down. Resident #1's hand was on Resident #2's genital area. She immediately separated the residents and told the charge nurse. However, there was no documented evidence of statements from other staff related to the allegation of sexual abuse between Resident #1 and Resident #2, on 05/17/2021. Review of facility staffing assignments, dated 05/17/2021, revealed CNA #6, CNA #9, CNA, #10 and RN #1 were assigned to the Arcadia Unit on 05/17/2021 6:00 AM/6:00 PM shift. Interview with CNA #6, on 09/22/2021 at 1:00 PM, revealed she worked on Arcadia Unit on 05/17/2021 6:00 AM/6:00 PM shift. Per interview, on 05/17/2021, she worked on Arcadia Unit with CNA #9, CNA #10, and Registered Nurse (RN) #1. Continued interview revealed on 05/17/2021 at approximately 3:00 PM, she observed Resident #1 in his/her room in bed and Resident #2 was noted sitting in a wheelchair in his/her room; both residents resided on the Arcadia Unit only doors apart. Additionally, she was in the shower room for ten (10) minutes after visualizing Resident #1 and Resident #2 and when she exited the shower room, she saw Resident #1 standing in front of Resident #2 with a rolling walker, in Resident #2's room. Resident #2 was seated in his/her wheelchair with his/her brief and pants pulled down to the knees with his/her legs spread. Resident #1's hands were in between Resident #2's legs touching his/her genital area. Further, she told the residents to stop; told Resident #2 to pull up his/her pants and closed the room door, and she escorted Resident #1 to the nurse's station and told RN #1 what she had walked in on. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed she worked on Arcadia Unit, on 05/17/2021 6:00 AM/6:00 PM shift. Per interview, the alleged sexual abuse between Resident #1 and Resident #2 was reported to the Director of Nursing (DON) who directed her to completed Skin Assessments on Resident #1 and Resident #2. Further, she was not aware if staff other than herself, on Arcadia Unit, were interviewed on 05/17/2021 (she did not provide a statement) or if residents on Arcadia Unit were assessed or interviewed; she did not participate in the investigation other than completing skin assessment for the two (2) residents. Interview with the Social Services Director (SSD), on 09/22/2021 at 5:06 PM, revealed she was the facility's Abuse Coordinator, and worked with the Administrator and nursing team to investigate abuse. Continued interview revealed she was responsible for interviewing residents and staff as directed by the Administrator or DON, related to allegations of abuse in the facility. Additionally, on 05/17/2021, she was informed by the DON of the alleged sexual abuse between Resident #1 and Resident #2 and that she needed to complete an assessment/interview with the residents; however, neither resident recalled the incident nor showed negative psychosocial outcomes. Further, she was not directed to complete any additional interviews with residents in the facility related to the allegation of abuse, on 05/17/2021. State Survey Agency (SSA) attempted to contact CNA #10, on 09/24/2021 at 12:14 PM. Telephone interview with CNA #9, on 09/24/2021 at 2:30 PM, revealed he worked on the Arcadia Unit on 05/17/2021. Continued interview, revealed on 05/17/2021, when the sexual abuse occurred, he was on the Arcadia Unit, however he was in another resident's room providing care. Additionally, he did recall CNA #6 talking about the sexual abuse between two (2) residents when CNA #10 came back from lunch. Further, he was not asked to provide a statement on 05/17/2021. Interview with the DON, on 09/23/2021 at 1:05 PM, revealed on 05/17/2021 at approximately 4:00 PM, she received a call from RN #1, related to resident-to-resident incident involving inappropriate sexual behaviors between Resident #1 and Resident #2. Continued interview revealed she initiated an investigation of the allegation of sexual abuse and directed RN #1 to complete Skin Assessments on Resident #1 and Resident #2 only, because there was only a small window of time the resident was not in line of sight of staff and very minimal potential an incident of the same nature had occurred with any other resident in the facility. Additional interview revealed, no further Skin Assessments on other resident's or interviews with staff or residents was completed because the of the small window Resident #1 was not visualized before the alleged sexual abuse. Continued interview revealed she did obtain statements/interviews from CNA #6 and both residents involved; however, no further statements were obtained because no other staff witnessed the alleged abuse and there were no other residents in the room, so their statements were not necessary. Further, the DON stated the allegation of sexual abuse between Resident #1 and Resident #2 was not abuse because both residents were cognitively impaired, and no harm occurred. Per interview, the facility's policy and procedure on abuse were followed. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed the DON informed her on 05/17/2021 between 1:00 PM and 4:00 PM that Resident #1 had his/her hand on Resident #2's privates. Additional interview revealed the Administrator directed the DON to initiate an abuse investigation, on 05/17/2020, following the facility's policy and procedures. Further interview revealed the DON interviewed Resident #1 and Resident #2; however, the Administrator did not direct the nursing department to complete skin assessments and resident interviews because the incident only involved Resident #1 and Resident #2. Per the Administrator statements were obtained from CNA #6 because she was the only staff member who witnessed the incident. Further interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed, she stated it was her responsibility, as the Administrator, to ensure all policies were followed to ensure systems were in place to protect all residents from abuse. Per interview, the facility investigation was a thorough investigation and they determined/concluded based on their investigation the root cause of the incident on 05/17/2021 was impaired cognition/confusion and abuse did not occur. The Administrator stated the facility's written policy(s) were implemented related to investigating an allegation of abuse for Resident #1 and Resident #2. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021 that alleged removal of the Immediate Jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of privacy. On 09/26/2021, the Minimum Data Set (MDS) Coordinators and the DON revised the care plan for Resident #1 to include constant one on one visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #1 was free from abuse. (c) On 09/24/2021, the DON reviewed the care plan for Resident #2 including the provision of privacy for any observed sexual behaviors and that privacy would be assured until the sexual behavior had concluded. On 09/26/2021, the MDS Coordinators and the DON revised the care plan for Resident #2 to include constant visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #2 was free from abuse. 2. (a) The Social Services Director (SSD) interviewed all interviewable residents on 09/24/2021 to solicit for any concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. These interviews were to be completed daily seven days a week by the SSD or assistant. (b) The Administrator mobilized the ReachAlert system, an automated communication system that can contact all staff, residents or their responsible parties by phone text or email, on 09/24/2021 to contact each employee and resident representative to solicit any resident concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. (c) From 09/24/2021 through 09/25/2021, the DON and Charge Nurse completed physical observations including skin assessments of each resident to assure that residents were free from abuse and neglect. 3. (a) On 09/24/2021, the facility secured a long-term care consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. The LTCC provided education to the Administrator on 09/24/2021 and 09/25/2021 regarding the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation. The Administrator completed a post-test on 09/26/2021. The education provided by the LTCC was according to the Abuse Prohibition Policies of the facility. (b) On 09/24/2021, the LTCC started meeting daily with the Administrator to review the practices and outcomes of education provided to the administrator who passed on the education to management staff that included the DON and the SSD. The education included the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation and to provide daily guidance. (c) From 09/24/2021 through 09/27/2021, the SSD and the DON, who were trained by the Administrator, and a charge nurse trained by the DON on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation, provided education to all employees of the facility and agency staff. Freedom from abuse, neglect and exploitation and resident rights was included in the education and according to the facility policies on abuse prevention and implementation of the facility abuse prohibition policies. Each employee received a post-test from 09/24/2021 through 09/27/2021 after receiving the education. Employees and agency staff that were off work and unavailable to work for any reason will receive this education and post-test before returning to work. (d) From 09/24/2021 through 09/26/2021, the MDS Coordinators and the DON completed resident care plan reviews to provide updates, needed revisions and care plan implementation daily to address the assessed needs related to supervision and monitoring to ensure a safe environment and prevent sexual abuse. 4. Beginning on 09/24/2021, the Quality Assurance Committee (QAC) conducted daily meetings seven (7) days per week to review actions taken and compliance with implementation of the abuse policies. The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 09/28/2021 as alleged: 1. (a) Review of the nursing notes for Resident #1 revealed the resident was moved to another room in the facility on a different unit on 05/17/2021. (b) Review of the record for Resident #1 revealed the facility revised the Care Plan was revised on 09/24/2021, 09/26/2021, and 09/27/2021. Interventions included redirection for any observed sexual behaviors, provision of privacy for sexual behaviors, and constant one-on-one visual supervision by staff. Observation of Resident #1 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided for Resident #1. (c) Review of the record for Resident #2 revealed the facility revised the Care Plan on 09/24/2021 and on 09/26/2021. The interventions included provision of privacy for sexual behaviors until the sexual behavior concluded and constant visual observation by staff trained in the abuse prohibition policies of the facility. Observation of Resident #2 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided. 2. (a) Interview with the SSD on 10/06/2021 at 2:59 PM revealed she completed interviews with all residents with a BIMS score of 8 or above on 09/24/2021 and has continued the interviews daily since that time. Review of Resident Daily Interviews and Observations log revealed residents of the facility with BIMS of 8 or above were interviewed daily beginning 09/24/2021. No concerns with abuse were identified. (b) Interview with the Administrator on 10/07/2021 at 11:21 AM revealed the ReachAlert system was mobilized on 09/24/2021 to solicit concerns from staff and resident representatives. The administrator stated the system was still being utilized daily and there had been no concerns verbalized through the system. Review of the emails printed from the ReachAlert system revealed messages had went out daily since 09/24/2021. (c) Review of Body Audits dated 09/25/2021 revealed the DON completed skin assessments of each resident on 09/25/2021. Interview with the DON on 10/07/2021 at 11:21 AM revealed she had completed the body audits on 09/25/2021 for any signs of abuse or neglect. Further review of the Body Audits revealed no concerns were identified. 3. (a) Interview on 10/07/2021 at 10:57 AM with the facility's LTCC revealed she started working with the Administrator on 09/24/2021 providing education regarding abuse. The LTCC stated that the Administrator had completed a post-test on 09/26/2021 regarding the education provided and no concerns were identified. (b) Review of the Administrator Education Log revealed the LTCC had met with the Administrator daily and had provided education related to abuse and neglect on a daily basis since 09/24/2021. The education included prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse allegations, timely assessment and revision of care plans, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse. Further review of the log revealed the Administrator had educated the DON and SSD. (c) Review of the Education Logs revealed from 09/24/2021 through 09/27/2021 all staff who were working or scheduled to work were retrained on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation. Further review of the Education Logs revealed copies of post-tests completed by the staff to ensure the education was effective. Interviews on 10/06/2021 with Housekeeper #14 at 2:30 PM, State Registered Nursing Assistant (SRNA) #9 at 2:50 PM, RN #1 at 3:29 PM, SRNA #6 at 3:55 PM, and SRNA #2 at 4:05 PM and interviews on 10/07/2021 with SRNA #7 at 10:15 AM revealed they had all received abuse education from the administration and the education included the different types of abuse, protection of the resident from further abuse, and immediate reporting of abuse. (d) Review of the Care Plan Audits revealed the MDS coordinators reviewed all resident care plans on 09/26/2021. Interview with RN #1 on 10/06/2021 at 3:29 PM revealed she was one of the MDS coordinators and completed a review of all resident care plans on 09/26/2021 and ensured behavioral interventions were current for each resident. 4. Review of the Quality Assurance (QA) Daily Meeting Logs revealed QA meetings were conducted daily from 09/24/2021 through 10/06/2021. Interview with the Administrator and the DON on 10/07/2021 at 11:21 AM revealed the QA meetings were on going and would continue until compliance was achieved.

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team (IDT) composed of individuals who had knowledge of the resident and his/her needs for three (3) of fifteen (15) residents; Resident #1, Resident #2, and Resident #3. The facility admitted Resident #1, on 09/08/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had severely impaired cognition and had a Power of Attorney (POA). The facility admitted Resident #3, on 10/11/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had intact cognitive response and a POA. The facility admitted Resident #2, on 03/04/2020, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had severely impaired cognition and had a state appointed Guardian. Interview and record review revealed on 03/04/2021 and 03/26/2021, the facility documented an incident related to Resident #1 attempting to make contact with other residents and the resident was placed on fifteen (15) minute checks. However, there was no documented evidence the Comprehensive Care Plan (CCP) was revised to include the behavior of attempting to touch other residents without permission or interventions to prevent or reduce further occurrences such as increased monitoring or supervision. Interview and record review revealed Resident #2 displayed sexually inappropriate behaviors on 05/13/2021, 05/14/2021, 05/15/2021 and 05/16/2021. However, there was no documented evidence the CCP was revised to include sexual type behaviors directed towards others. Further, there was no evidence the CCP was revised to include interventions to prevent or reduce further occurrences such as increased monitoring or supervision. Subsequently, on 05/17/2021, Resident #1 entered Resident #2's room. Resident #2 had his/her pants and underwear pulled down and Resident #1 touched Resident #2's genital area. However, there was no documented evidence the facility identified the need to increase monitoring or supervision of Resident #1 after a room change and thirty (30) minutes of one (1) to one (1) supervision. Additional record review for Resident #1 revealed on 05/18/2021, Resident #3 wheeled up to Resident #1 and kissed him/her on the lips. However, there was no documented evidence the facility identified the need to revise Resident #3's CCP to include the specific behavior directed towards other residents or interventions to prevent or reduce further occurrences. Further review of Resident #1's Behavior Monitoring sheets, dated 05/23/2021 and 05/30/2021, revealed Resident #1 wandered into other resident rooms; however, there was no documented evidence of interventions to prevent or reduce further occurrences such as increased monitoring or supervision. The facility's failure to have an effective system in place to ensure CCP's were reviewed and revised for each resident, for residents with behaviors, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/21/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/21/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/05/2021, with the facility alleging removal of the Immediate Jeopardy on 09/28/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/28/2021, prior to exit on 10/07/2021. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy title, Comprehensive Care Plan, dated 07/17/ , revealed the Comprehensive Care Plan directed how each resident's daily care needs were provided by staff in accordance with the guidelines and the Resident Assessment Instrument (RAI) process and the Medicare/Medicaid Service requirements. Per policy, residents received care and treatment based on an assessment of their needs, and an individualized, person centered CCP was developed that identified the highest level of functioning the resident may be expected to attain. Additional review revealed the CCP was revised as changes in the resident's condition dictated. The care plan was reviewed at least quarterly, and each discipline was responsible for developing a problem identification list. Further, the maintenance of a resident's care plan was an interdisciplinary team (IDT) process. Per policy, the progress of a resident would be evaluated as necessary, and the plan of care would be revised as indicated. The resident goals and plan of action would be updated by the individual who identified the problem, or by the IDT according to their expertise and credentials Review of the CMS, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the CCP must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the CCP was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a CCP based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and CCP re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI, and then, the individualized CCP was modified as appropriate and necessary. 1. Review of Resident #1's medical record revealed the facility admitted the resident, on 09/08/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #1's medical record revealed the resident had a POA. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's CCP, dated 01/02/2019, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e., inappropriate touching or comments to female staff related to dementia with behaviors). The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; medicate as ordered; offer diversional activity; state to the resident stop sexual misconduct while immediately distancing resident to prevent harm from aggression, verbal praise the residents non-violent problem solving behaviors; and verbally confront the wrong doing or breech of another's personal rights and request future restraint/cessation of behavior, verbally praise compliance. Further review of Resident #1's CCP, dated 01/20/2021, revealed the resident had impaired cognition related to Alzheimer's Dementia and Panic Disorder. The goal was the resident would not show decline in cognitive function daily. Continued review revealed interventions that included but were not limited to: reduce distractions and negative environmental stimulus as much as possible; offer simple choices allowing sufficient time for decision making; allow the resident to discuss feelings or anger/powerlessness/frustration as needed. Interview with CNA #9 on 09/22/2021 at 12:30 PM, revealed she had worked at the facility for three (3) years. Additionally, Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the resident was known to attempt to reach/touch female residents in the facility. Interview with CNA #6, on 09/22/2021 at 1:00 PM revealed she had worked at the facility for three (3) years. Additionally, Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was known to attempt to reach/touch female residents in the facility. Further, staff attempted to distance other residents away from Resident #1 because of his/her behaviors. However, review of Resident #1's CCP with the CNA's revealed no documented evidence of the specific behaviors or interventions to prevent or reduce further occurrence. Review of Resident #1's Progress Note, dated 03/08/2021 at 3:07 PM, written by Registered Nurse (RN) #2, revealed the resident was attempting to touch peers (other residents) without permission. Further, the Note stated the resident was redirected away from area with frequent checks. Additional record review revealed Fifteen (15) Minute Checks were initiated on 03/08/2021; Resident #1 was provided visualization from staff at least every fifteen (15) minutes. However, review of Resident #1's CCP revealed there was no documented evidence the care plan was revised to include the behavior of attempting to touch other residents or the increased supervision on 03/08/2021. Further, there was no evidence the CCP was revised to include interventions to prevent or reduce further occurrences. Review of Resident #1's Progress Note, dated 03/24/2021 at 2:14 PM, written by RN #2, revealed the resident was in the television room a few times throughout the day; one (1) time he/she required redirection due to reaching for a female peer (resident). Additionally, the resident was reminded about respecting space and Resident #1 left the television area. Further, the POA and Physician were notified. Continued review of the medical record revealed Fifteen (15) Minute Checks were extended after the 03/24/2021 incident where Resident #1 attempted to reach for a female resident. Additional review revealed Fifteen (15) Minute Checks continued through 03/29/2021; the resident was provided visualization from staff at least every fifteen (15) minutes. However, review of the CCP revealed no documented evidence the care plan was revised to include the behavior or attempting to touch other residents or increased supervision on 03/24/2021. Further, there was no evidence the CCP was revised to include interventions to prevent or reduce further occurrences. Interview with RN #2, on 09/24/2021 at 11:20 AM, revealed Resident #1 had sexually inappropriate behaviors towards staff and would attempt to reach out and touch residents; however, he had never got another resident. Additionally, the resident wandered and got lost when attempting to find his/her room. Further, on 03/08/2021 and 03/24/2021, after the resident's attempts to touch other residents, the CCP should have been revised to include the increased supervision and behaviors so all staff knew what was going on with the resident and how to provide adequate care. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/21/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision of one (1) staff for transfers, ambulation, and locomotion with a walker. Review of Resident #1's Progress Note, dated 05/17/2021 at 4:00 PM, written by the Director of Nursing (DON), revealed the resident was involved in resident contact with another peer (resident). Further, no injury was noted, and the resident and peer (resident) were immediately separated. Additional review of Resident #1's Progress Note, dated 05/17/2021 at 4:30 PM, written by the DON, revealed the resident remained with staff until his/her room change was completed. Additionally, the room change was completed at that time, and the resident was assisted to the new room and introduced to his/her roommates, oriented to the room and the call light. Further record review for Resident #1 revealed no documented evidence the CCP was revised to include the behavior of touching other resident's genital areas or increase supervision until after the sexual contact with another resident, on 05/17/2021. Further, there was no evidence the CCP was revised to include interventions to prevent or reduce further occurrences. Review of Resident #1's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on 05/23/2021 6:00 AM/6:00 PM shift, the resident was confused and went into wrong rooms. Further review revealed on 05/30/2021 6:00 AM/6:00 PM shift, the resident was confused and wandered. However, there was no evidence the CCP was revised to the behavior of wandering or to include interventions to prevent or reduce further occurrences. Continued review of Resident #1's Mood and Behavior Patterns flowsheet, dated June 2021, revealed on 06/06/2021 6:00 AM/6:00 PM shift, the resident was confused and wandered into other rooms. However, there was no evidence the CCP was revised to the behavior of wandering or to include interventions to prevent or reduce further occurrences. 2. Review of Resident #2's medical record revealed the facility admitted the resident, on 03/04/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #2's medical record revealed the resident had a State Guardian. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS Assessment, dated 02/02/2021, revealed the facility assessed the resident as having a BIMS score of four (4) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision to limited assistance of one (1) staff for transfers, ambulation, and locomotion with a wheelchair. Review of Resident #2's CCP, dated 03/05/2020, revealed the resident had impaired cognition related to Alzheimer's Dementia. The goal was the resident would be able to make needs known daily. Continued review revealed interventions that included but were not limited to: allow time for the resident to express self, do no rush, anticipate needs; allow the resident to express feelings of anger/powerlessness and frustration; avoid commands like don't and no; offer simple choices; and reduce distractions and negative environment. Continued review of Resident #2's CCP, dated 09/28/2020, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e., inappropriate sexual comments) related to Dementia with behaviors. The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; and offer diversional activities. Additionally, the CCP was revised on 05/13/2021, to include exposing genitals as an example of inappropriate/disruptive behaviors. Review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed On 05/13/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior not directed at other in the television room. Staff redirected the resident to his/her room, closed the curtain and door. Review of Resident #2's Progress Note, dated 05/13/2021 at 7:05 AM, written by the DON, revealed the resident was observed in the television room and had removed his/her brief exposing his/her peri-area. Additionally, the resident was redirected and assisted with dressing. However, there was no documented evidence the CCP was revised to include the specific behaviors or interventions to prevent or reduce further occurrences. Continued review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on 05/14/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior, hunching in wheelchair, in the television room. Staff redirected the resident to his/her room. Further review of Resident #2's CCP, dated 05/14/2021, revealed the resident exhibited social inappropriate behavior as evidence by masturbating in non-private areas. The intervention was to redirect/assist the resident to a room and reiterate the need for privacy (close door, draw curtain) when performing self-pleasure. However, there was no further documented evidence the CCP was revised to include interventions to prevent or reduce further occurrences. Additional review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on the weekend of 05/15/2021 and 05/16/2021, on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behaviors. Staff provided verbal cues. Interview with CNA #9 on 09/22/2021 at 12:30 PM and CNA #6, on 09/22/2021 at 1:00 PM revealed Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the resident would make comments to staff; look at his/her butt, hey good looking, and try to whistle or call out. However, in the middle of May 2021, the resident's behaviors changed and were more frequent and had intensified. The CNA's reported the behaviors to nurses. The resident made foul and vulgar comments to staff, would touch his/her private body parts in commons areas, would undress in common areas, and hunch and grind on his/her wheelchair seat. Further, they were directed by nurses to redirect the resident and ensure his/her privacy was maintained. However, there was no documented evidence the CCP was revised to include sexual type behaviors: exposing his/herself in common areas, touching staff, grinding and hunching in the wheelchair, or vulgar comments directed towards others. Review of Resident #2's Progress Note, dated 05/17/2021 at 4:00 PM, written by the DON, revealed the resident was involved in resident contact with another peer (resident). Additionally, no distress was noted, and the resident and peer (resident) were immediately separated. Further, the Medical Director (MD) and POA were aware. Review of Resident #1 and Resident #2's Incident Reports, dated 05/17/2021, completed by the DON, revealed an incident of resident contact occurred between Resident #1 and Resident #2, who were confused and mobile with assistive devices. Per Report, Resident #1 was observed in Resident #2's room with his/her hand resting on Resident #2's peritoneal area; Resident #2's clothing was pulled down. Continued review revealed the residents were separated and no distress was noted. Additionally, the residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Per Reports, Resident #1 had a room change to decrease interaction with Resident #2, who was sexually seeking attention; Resident #1 and Resident #2 were placed on fifteen (15) minute checks. However, there was no documented evidence Resident #1's CCP was revised after 05/17/2021 to include the specific behavior or touching other residents' genitals or interventions to reduce or prevent further occurrence or no documented evidence Resident 2's CCP was revised to include the recent heightened sexual type behaviors. Further, there was no evidence Resident #1 or Resident #2's CCP was revised to include interventions to prevent or reduce further occurrences of those behaviors. 3. Review of Resident #3's medical record revealed the facility admitted the resident, on 10/11/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, review of the medical record revealed the resident had a POA. Review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 03/23/2021, revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15), indicating intact cognitive response. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required extensive assistance of one (1) staff for transfers, ambulation, and locomotion with a wheelchair. Review of Resident #3's CCP, dated 10/18/2019, revealed the resident had impaired cognition related to Dementia. The goal was the resident would be able to make simple needs known daily. Continued review revealed interventions that included but were not limited to: allow time for the resident to express self, do no rush, anticipate needs; allow the resident to express feelings of anger/powerlessness and frustration; avoid commands like don't and no; offer simple choices; and reduce distractions and negative environment. Continued review of Resident #3's CCP, dated 07/15/2020, revealed the resident exhibited aggressive outburst or disruptive behaviors (i.e., threatens to hit at other residents/staff, curses loudly) related to Dementia. The goal was the resident would demonstrate reduced episodes of outburst. Continued review revealed interventions included but were not limited to: approach from the front; consider activities prior to outburst; immediately report incidents to nursing, social services or administration; and remind the resident the necessity to refrain from outburst. Interview with CNA #6, on 09/22/2021 at 1:00 PM revealed Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, she reported the behaviors to nurses. Further staff were told to redirect and reorient the resident. Interview with RN #1, on 09/22/2021 at 2:54 PM and with RN #2, on 09/24/2021 at 11:20 AM, revealed Resident #3 was confused all the time and often wandered and confused other residents as his/her spouse. Further, the resident needed supervision and redirection. However, there was no documented evidence the CCP was revised to include behaviors of confusing other residents as his/her spouse, wandering/seeking his/her spouse, bible or pocketbook. Review of Resident #3's Progress Note, dated 05/18/2021 at 7:15 AM, written by the DON, revealed the resident was involved in resident contact with another peer (resident). Additionally, the Medical Director (MD) and POA were notified. Further, the resident was placed on fifteen (15) minutes checks. Review of Resident #3's Incident Report, dated 05/18/2021 at 7:15 AM, written by the DON, revealed Resident #1 was sitting in the television room and Resident #3 rolled his/her wheelchair up the resident and kissed them on the lips. Additional review revealed Resident #3 stated he/she kissed their spouse. Continued review revealed Certified Nursing Assistant (CNA) #11 witnessed the incident. Per Report, Resident #3 was placed on fifteen (15) minute checks. Further, the MD and POA were notified. However, there was no documented evidence Resident #3's CCP was revised after 05/18/2021 to include the specific behavior of kissing another residents or interventions to reduce or prevent further occurrence of that behavior. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed the CCP should have been updated to reflect individualized behaviors and interventions that were needed to ensure resident safety, related to Resident #1, Resident #2, and Resident #3. Further the CCP's should be revised timely and accurately, as per the facility's CCP policy. Interview with the RN #4, 09/22/2021 at 5:50 PM, revealed the facility utilized the CMS Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for CCP's. She stated at the morning clinical meetings, staff discussed incidents. Per the interview, any staff nurse had access to revise the care plan. Further, she stated it was important to have a current, accurately revised CCP to ensure direct care staff would know how to provide care to residents to meet their needs. Continued interview with RN #2, on 09/24/2021 at 11:20 AM, revealed any nurse could revise the care plan. She stated nurses depended on each other and management to ensure appropriate interventions were in place and person centered for each resident. Per the interview, when any resident exhibited behaviors, the CCP should be revised to include that increased behavior and interventions to help the resident with the behavior. Interview with the DON, on 09/23/2021 at 1:05 PM, revealed she expected the CCP's to be revised accurately, as per the facility's policies. Per the interview, all nurses were responsible for revision of the electronic version of the CCP, including any changes related to behaviors. Additionally, she stated the current process in place was, during the facility's Morning Clinical Meeting, held on Monday through Friday, a review of all incidents and of the CCP's was completed to ensure revisions were made as necessary. Continued interview revealed Resident #1's, Resident #2's and Resident #3's CCP's should have been revised to include specific behaviors and interventions to minimize those behaviors. In addition, the DON stated the CCP's should be revised as necessary to ensure residents received appropriate services and individualized care. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed the facility was to utilize the RAI Manual and facility policies as resources to ensure the CCP was revised as necessary. She stated it was important for the CCP to be revised accurately to reflect a resident's current status and ensure the CCP addressed each resident's individual needs. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021 that alleged removal of the Immediate Jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of privacy. On 09/26/2021, the Minimum Data Set (MDS) Coordinators and the DON revised the care plan for Resident #1 to include constant one on one visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #1 was free from abuse. (c) On 09/24/2021, the DON reviewed the care plan for Resident #2 including the provision of privacy for any observed sexual behaviors and that privacy would be assured until the sexual behavior had concluded. On 09/26/2021, the MDS Coordinators and the DON revised the care plan for Resident #2 to include constant visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #2 was free from abuse. 2. (a) The Social Services Director (SSD) interviewed all interviewable residents on 09/24/2021 to solicit for any concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. These interviews were to be completed daily seven days a week by the SSD or assistant. (b) The Administrator mobilized the ReachAlert system, an automated communication system that could contact all staff, residents or their responsible parties by phone text or email, on 09/24/2021 to contact each employee and resident representative to solicit any resident concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. (c) From 09/24/2021 through 09/25/2021, the DON and Charge Nurse completed physical observations including skin assessments of each resident to assure that residents were free from abuse and neglect. 3. (a) On 09/24/2021, the facility secured a long-term care consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. The LTCC provided education to the Administrator on 09/24/2021 and 09/25/2021 regarding the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation. The Administrator completed a post-test on 09/26/2021. The education provided by the LTCC was according to the Abuse Prohibition Policies of the facility. (b) On 09/24/2021, the LTCC started meeting daily with the Administrator to review the practices and outcomes of education provided to the administrator who passed on the education to management staff that included the DON and the SSD. The education included the prevention of abuse, implementing abuse po [TRUNCATED]

Based on observation, interview, record review, review of the Assistant Director of Nursing, the Director of Nursing, and the Administrator's Job Descriptions, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident to ensure residents were free from abuse. The facility's Administration failed to ensure the facility followed its Abuse, Neglect, and Exploitation Policy or the Investigation policy when an allegation of sexual abuse occurred at the facility. In addition, Administration did not ensure residents were protected. Once the alleged sexual abuse was identified, Administration did not ensure the facility followed its Close Observations; One (1) to One (1) Supervision; 15 Minute Checks policy after an allegation of sexual abuse occurred at the facility. Further, Administration failed to ensure the facility revised the resident's plans of care to ensure adequate monitoring and supervision. The facility's failure to have an effective system in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure residents were free from abuse; thoroughly investigate allegations of abuse; protect residents; establish and maintain a safe environment with adequate supervision to prevent abuse; and, its failure to revise residents' care plans to [MEDICATION(S)] to prevent abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/21/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/21/2021. The facility provided an acceptable Credible Allegation of Compliance (AoC), on 10/05/2021, alleging removal of the Immediate Jeopardy, on 09/28/2021. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 09/28/2021, prior to exit, on 10/07/2021. The findings include: Post survey interview with the Administrator, on 10/12/2021 at 3:25 PM, revealed the facility did not have a written policy related to Administration; however, the facility considered herself and the administrative nurse (the Director of Nursing {DON}) as Administration. Review of the facility's Job Description for Administrator, dated 06/05/2017, revealed the Administrator's job was to develop, manage, and direct health care programs in the facility. Continued review revealed the Administrator was responsible for managing employees and maintaining regulatory compliance. Additional review revealed duties included demonstrated abilities in regulatory compliance; work in conjunction with regulatory officials to ensure the safety, health, quality of life and quality of care for individuals residing within the facility. Per Job Description, the Administrator, in conjunction with the Social Services Director (SSD) and the DON were responsible to work with allegations of abuse and to report abuse to appropriate agencies. Further review revealed the Administrator completed annual performance evaluations of Department Directors and others who directly reported to the Administrator; conducted weekly staff meetings and sat as a Chairman on the Quality Assurance Committee. Review of the facility's Job Description for Director of Nursing (DON), undated, revealed the DON reported to the Administrator and supervised all nursing staff. Further review revealed the DON, being directly responsible to the Administrator, was responsible for on-going nurse training; quality monitoring; and evaluation of the overall nursing program. Review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed each resident should be afforded Resident Rights, including the right to be free from verbal, sexual, physical, and mental abuse. Per the facility's policy, there were seven (7) components that served as a foundation to uphold Resident Rights to be free from abuse: screening, training, prevention, identification, investigating, protection, and reporting/response. Additionally, if a resident-to-resident incident occurred, the resident safety and protection would be assured. Continued review of the policy revealed an investigation would be performed to determine if abuse occurred; a thorough assessment would be completed for the resident(s) and the Responsible Party/Guardian, Attending Physician, the Department of Community Based Services (DCBS) and the Division of Long-Term Care would be notified within two (2) hours. Further if the allegation was verified, appropriate corrective action would be taken. Additional review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed the facility mandated that the right of individuals to be protected as outlines in the state and federal regulation and staff were responsible for the health, safety, and welfare of all residents. Per the facility's policy, abuse, including sexual abuse, was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful was define as deliberate action, not that the individual intended to inflict injury or harm; and sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with residents. Individuals subject to abuse had the right to be immediately examined by their physician. Further, allegations would be thoroughly investigated by the Abuse Coordinator, Administrator, or designee. An Incident Report would be completed documenting the findings. Continued review revealed the Administrator or designee would take prompt action to protect the individuals. A written report of the investigation would be prepared by the Administrator or designee and completed within five (5) working days of the incident. Review of the facility policy, Investigation, undated, revealed all incidents that occurred in the facility required a thorough investigation and accurate documentation to evaluate and determine why incidents occurred, take corrective action to curtain the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. Additionally, the Charge Nurse or Department Head on duty at the time of the incident would conduct the investigation. Per the policy, a prompt response to identified incidents was imperative to obtain accurate date and to treat ill effects experienced by residents from the alleged incident and to safeguard residents from further incident. Continued review revealed a thorough, complete investigation was intended to allow the facility to identify and document who was involved in the incident and establish the how, what, when, where, who and why the incident happened. The investigation should focus on whether the allegation was substantiated or unsubstantiated. Further the investigation required data collection from those who were involved, who may have information related to the incident and what the chronological order of action leading up to the incident, what the witness saw, what information other staff member knew, what was known about those involved in the incident. Continued review revealed the alleged victim and suspect, as well as caregivers in the immediate area should be interviewed. Review of the facility's policy titled, Determination of Mental Capacity for Decision Making, undated, revealed the purpose was to ascertain if a resident had the mental capacity to express themselves. Per the policy, capacity was defined as the most basic level means that a resident had the ability to understand potential consequences and choose a course of action for a given situation. Additionally, resident who were deemed as moderately impaired or cognitively intact, had the capacity to make decisions including, but not limited to, decisions related to care, treatment, safety, and autonomy. Continued review revealed upon admission, quarterly and with significant change, mental capacity was reviewed or determined by the Social Services Director. Referring resources, the residents, and their responsible party collaborated information regarding prior determinations such as guardianship, power of attorney (POA), hospital records and other documentation of mental status. The facility determined the type of decisions that must be made by legal responsible parties and those the resident could make according to the assessment of mental capacity, legal requirements, and prior determination. Further, residents were required to complete a Brief Interview of Mental Status (BIMS) as part of the admission assessment, quarterly review and with any significant change. Resident who scored zero (0) to seven (7) indicated severe cognitive impairment and would not be considered able to make decisions; therefore, the resident representative had legal authority to address decision making in areas of concern and the facility would respect the representative's decision. Review of the facility's policy titled, Close Observations; One (1) to One (1) Supervision; 15 Minute Checks, revised 02/22/2013, revealed the facility would provide the safest environment possible and/or prevent injury for all residents. Continued review revealed Close Observation was defined as within sight at all times; One (1) to One (1) Supervision was defined as in sign and reach at all times; and Fifteen (15) Minute Checks was defined as actual visualization at least every fifteen (15) minutes. Per the policy, the above would be initiated as needed for a number of reasons, i.e., agitation, unpredictable or aggressive behaviors; after sedation; suicidal thoughts or threats; falls; or any time a resident safety was an issue. Additionally, the Charge Nurse was responsible for assessing the Resident/situation and making the decision for the appropriate need (Close Observation; One {1} on One {1}; or Fifteen {15} Minute Checks). The Charge Nurse was also responsible to assign staff and explain what was expected of them and what they were to prevent. Continued review revealed a monitoring form would be started noting the resident's name, time initiated, and the appropriate need (Close Observation; One {1} on One {1}; or Fifteen {15} Minute Checks). Further, the resident/situation would be assessed every shift for the need to continue or resolve the increased supervision; documentation would be included in the medication record including the rationale. Continued review revealed communication to each on coming shift would be provided related to the increased supervision. The Physician and Responsible Party would be informed of the situation which required increased supervision. Review of the facility's policy title, Comprehensive Care Plan, dated 07/17/ , revealed the Comprehensive Care Plan (CCP) directed how each resident's daily care needs were provided by staff in accordance with the guidelines and the Resident Assessment Instrument (RAI) process and the Medicare/Medicaid Service requirements. Per policy, residents received care and treatment based on an assessment of their needs, and an individualized, person centered CCP was developed that identified the highest level of functioning the resident may be expected to attain. Additional review revealed the CCP was revised as changes in the resident's condition dictated. The care plan was reviewed at least quarterly, and each discipline was responsible for developing a problem identification list. Further, the maintenance of a resident's care plan was an interdisciplinary team (IDT) process. Per the policy, the progress of a resident would be evaluated as necessary, and the plan of care would be revised as indicated. The resident goals and plan of action would be updated by the individual who identified the problem, or by the IDT according to their expertise and credentials Per record review, Resident #1 and Resident #2 were involved in an allegation of sexual abuse on 05/17/2021. However, review of the Five (5) day Investigation, dated 05/20/2021, revealed the facility unsubstantiated the allegation of sexual abuse and determined the root cause of the occurrence was impaired cognition. Administrative staff believed Resident #2's sexual behaviors not directed towards others initiated/provoked Resident #2's sexual behaviors towards Resident #1 and the residents were confused. Therefore, administrative staff did not identify the incident as sexual assault/abuse, even though the residents had not been assessed to have capacity to consent to sexual behaviors and it was documented Resident #2 touched Resident #1's genital area. Additionally, through interviews and review of the facility's investigation, the Administration failed to ensure the facility's Abuse policy(s) were followed; abuse was investigated thoroughly, and residents were protected. Interviews, on 09/22/2021 at 1:00 PM, with CNA #6; on 09/22/2021 at 2:54 PM, with RN #1; and on 09/24/2021 at 2:30 PM, with CNA #9 revealed the alleged sexual abuse in its entirety was not witnessed by staff on 05/17/2021. RN #1, CNA #6, CNA #9 and CNA#10 (unavailable for interview) were assigned to Resident #1 and Resident #2's hallway; however, they were off the hallway, with other residents behind closed doors or on lunch, when the alleged sexual abuse occurred; therefore, they could not account for the time the residents were unsupervised and the abuse occurred. Interview with Administrative staff revealed they did not obtain statements from all staff assigned to Resident #1 and Resident #2's hallways or interview or assess other residents in the facility because based on the one (1) interview they did obtain from CNA #6, Resident #1 and Resident #2 were not visualized by staff for approximately ten (10) minutes and there were no other residents in the room when the alleged sexual abuse occurred. Further, administrative staff failed to increase supervision and monitoring for Resident #1 after a room change, on 05/17/2021, because Resident #2 had instigated the behaviors of Resident #1. Administration failed to identify the need for Resident #1 to have increased monitoring and supervision to ensure residents were safe from his/her potential actions. Further, through interview and record review, the Administration failed to ensure the facility's policy on Comprehensive Care Plan policy was followed. Interviews, on 09/22/2021 at 2:54 PM, with RN #1 and on 09/22/2021 at 5:06 PM, with Social Services Director (SSD) revealed Resident #1 and Resident #2's sexual behaviors directed towards other residents and interventions to prevent or reduce further occurrences such as increased monitoring or supervision should have been included on the CCP. Interview with administrative staff revealed they failed to identify the need for Resident #1's CCP to be revised related to resident specific behaviors to include touching other residents sexually or interventions to prevent or reduce further occurrence of sexual behaviors directed towards others. Interview with the Director of Nursing (DON), on 09/23/2021 at 1:05 PM, revealed she was notified on 05/17/2021 related to sexual behaviors with Resident #1 and Resident #2. She immediately initiated an investigation; however, she did not obtain statements from staff assigned to the resident's hallway and she did not interview or assess other residents in the facility. Additionally, she did not identify the need to increase Resident #1's monitoring or supervision after a room change. Further she did not identify that Resident #1's CCP was not revised to include the individualized resident centered behaviors or interventions to prevent further occurrences of sexual behaviors directed at other residents. Further the DON stated she had followed the facility's policy and procedure on Abuse, and all residents were safe and protected from abuse. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed it was her expectation the facility's policy(s) to be followed. She stated staff should be knowledgeable of the policy and know expectations related to protecting residents, investigating abuse, providing adequate supervision, and revisions to the CCP. Per interview, the Administrator stated a thorough investigation had been completed for the allegation on 05/17/2021, and the residents were protected; no further abuse occurred. Further interview revealed she interpreted Resident #1's CCP to address his/her behaviors were directed to both residents and staff and no revision was necessary. Continued interview with the Administrator revealed it was her responsibility to ensure oversight of the facility. She stated she ensured residents were protected from abuse. She stated Administrative Staff ensured the Abuse policy(s), Close Observation policy and Comprehensive Care Plan policy were enforced and implemented and there was no further abuse in the facility. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021 that alleged removal of the Immediate Jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of privacy. On 09/26/2021, the Minimum Data Set (MDS) Coordinators and the DON revised the care plan for Resident #1 to include constant one on one visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #1 was free from abuse. (c) On 09/24/2021, the DON reviewed the care plan for Resident #2 including the provision of privacy for any observed sexual behaviors and that privacy would be assured until the sexual behavior had concluded. On 09/26/2021, the MDS Coordinators and the DON revised the care plan for Resident #2 to include constant visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #2 was free from abuse. 2. (a) The Social Services Director (SSD) interviewed all interviewable residents on 09/24/2021 to solicit for any concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. These interviews were to be completed daily seven days a week by the SSD or assistant. (b) The Administrator mobilized the ReachAlert system, an automated communication system that could contact all staff, residents or their responsible parties by phone text or email, on 09/24/2021 to contact each employee and resident representative to solicit any resident concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. (c) From 09/24/2021 through 09/25/2021, the DON and Charge Nurse completed physical observations including skin assessments of each resident to assure that residents were free from abuse and neglect. 3. (a) On 09/24/2021, the facility secured a long-term care consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. The LTCC provided education to the Administrator on 09/24/2021 and 09/25/2021 regarding the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation. The Administrator completed a post-test on 09/26/2021. The education provided by the LTCC was according to the Abuse Prohibition Policies of the facility. (b) On 09/24/2021, the LTCC started meeting daily with the Administrator to review the practices and outcomes of education provided to the administrator who passed on the education to management staff that included the DON and the SSD. The education included the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation and to provide daily guidance. (c) From 09/24/2021 through 09/27/2021, the SSD and the DON, who were trained by the Administrator, and a charge nurse trained by the DON on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation, provided education to all employees of the facility and agency staff. Freedom from abuse, neglect and exploitation and resident rights was included in the education and according to the facility policies on abuse prevention and implementation of the facility abuse prohibition policies. Each employee received a post-test from 09/24/2021 through 09/27/2021 after receiving the education. Employees and agency staff that were off work and unavailable to work for any reason would receive this education and post-test before returning to work. (d) From 09/24/2021 through 09/26/2021, the MDS Coordinators and the DON completed resident care plan reviews to provide updates, needed revisions and care plan implementation daily to address the assessed needs related to supervision and monitoring to ensure a safe environment and prevent sexual abuse. 4. Beginning on 09/24/2021, the Quality Assurance Committee (QAC) conducted daily meetings seven (7) days per week to review actions taken and compliance with implementation of the abuse policies. The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 09/28/2021 as alleged: 1. (a) Review of the nursing notes for Resident #1 revealed the resident was moved to another room in the facility on a different unit on 05/17/2021. (b) Review of the record for Resident #1 revealed the facility revised the Care Plan on 09/24/2021, 09/26/2021, and 09/27/2021. Interventions included redirection for any observed sexual behaviors, provision of privacy for sexual behaviors, and constant one-on-one visual supervision by staff. Observation of Resident #1 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided for Resident #1. (c) Review of the record for Resident #2 revealed the facility revised the Care Plan on 09/24/2021 and on 09/26/2021. The interventions included provision of privacy for sexual behaviors until the sexual behavior concluded and constant visual observation by staff trained in the abuse prohibition policies of the facility. Observation of Resident #2 on 10/06/2021 and 10/07/2021 revealed one-on-one staff supervision was being provided. 2. (a) Interview with the SSD, on 10/06/2021 at 2:59 PM, revealed she completed interviews with all residents with a BIMS score of 8 or above on 09/24/2021 and has continued the interviews daily since that time. Review of Resident Daily Interviews and Observations log revealed residents of the facility with BIMS of 8 or above were interviewed daily beginning 09/24/2021. No concerns with abuse were identified. (b) Interview with the Administrator, on 10/07/2021 at 11:21 AM, revealed the ReachAlert system was mobilized on 09/24/2021 to solicit concerns from staff and resident representatives. The Administrator stated the system was still being utilized daily and there had been no concerns verbalized through the system. Review of the emails printed from the ReachAlert system revealed messages had went out daily since 09/24/2021. (c) Review of Body Audits, dated 09/25/2021, revealed the DON completed skin assessments of each resident on 09/25/2021. Interview with the DON on 10/07/2021 at 11:21 AM revealed she had completed the body audits on 09/25/2021 for any signs of abuse or neglect. Further review of the Body Audits revealed no concerns were identified. 3. (a) Interview with the facility's LTCC, on 10/07/2021 at 10:57 AM, revealed she started working with the Administrator on 09/24/2021 providing education regarding abuse. The LTCC stated that the Administrator had completed a post-test on 09/26/2021 regarding the education provided and no concerns were identified. (b) Review of the Administrator Education Log revealed the LTCC had met with the Administrator daily and had provided education related to abuse and neglect on a daily basis since 09/24/2021. The education included prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse allegations, timely assessment and revision of care plans, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse. Further review of the log revealed the Administrator had educated the DON and SSD. (c) Review of the Education Logs revealed from 09/24/2021 through 09/27/2021 all staff who were working or scheduled to work were retrained on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation. Further review of the Education Logs revealed copies of post-tests completed by the staff to ensure the education was effective. Interviews on 10/06/2021 with Housekeeper #14 at 2:30 PM, State Registered Nursing Assistant (SRNA) #9 at 2:50 PM, RN #1 at 3:29 PM, SRNA #6 at 3:55 PM, and SRNA #2 at 4:05 PM and interviews on 10/07/2021 with SRNA #7 at 10:15 AM revealed they had all received abuse education from the administration and the education included the different types of abuse, protection of the resident from further abuse, and immediate reporting of abuse. (d) Review of the Care Plan Audits revealed the MDS coordinators reviewed all resident care plans on 09/26/2021. Interview with RN #1 on 10/06/2021 at 3:29 PM revealed she was one of the MDS coordinators and completed a review of all resident care plans on 09/26/2021 and ensured behavioral interventions were current for each resident. 4. Review of the Quality Assurance (QA) Daily Meeting Logs revealed QA meetings were conducted daily from 09/24/2021 through 10/06/2021. Interview with the Administrator and the DON on 10/07/2021 at 11:21 AM revealed the QA meetings were on going and would continue until compliance was achieved.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent abuse for two (2) of fifteen (15) residents; Resident #1 and Resident #2. The facility admitted Resident #1, on 09/08/2017, with diagnoses to include Alzheimer's Dementia, [CONDITION(S)], Anxiety, Depression, and High-Risk Heterosexual Behaviors. Record review revealed the resident had severely impaired cognition and had a Power of Attorney (POA). The facility admitted Resident #2, on 03/04/2020, with diagnosis to include Alzheimer's Dementia, Dementia with Behavioral Disturbances and Mood Affect Disorder. Record review revealed the resident had severely impaired cognition and had a state appointed Guardian. Interview and record review revealed Resident #2's sexually inappropriate behaviors on 05/13/2021, 05/14/2021, 05/15/2021 and 05/16/2021. However, there was no documented evidence the facility increased monitoring or supervision of the residents or revised the care plan to include sexual type behaviors directed towards others. Subsequently, on 05/17/2021, Resident #1 entered Resident #2's room. Resident #2 had his/her pants and underwear pulled down and Resident #1 touched Resident #2's genital area. However, there was no documented evidence the facility identified the need to increase monitoring or supervision of Resident #1 after a room change and thirty (30) minutes of one (1) to one (1) supervision. Record review revealed Resident #1 was involved in a Resident-to-Resident incident on 05/18/2021 where another resident kissed him/her on the lips. Continued review of Resident #1's Behavior Monitoring sheets, dated 05/23/2021 and 05/30/2021, revealed Resident #1 had wandered into other resident rooms; however, there was no documented evidence of interventions to prevent or reduce further occurrences such as increased monitoring or supervision. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent avoidable accidents/hazards, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, on 09/24/2021, and determined to exist, on 05/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, F-600 Free from Abuse at S/S of J, F-607 Develop and Implement Abuse Policy at S/S of J, F-610 Investigation of Abuse at S/S of J, 42 CFR 482.21 Comprehensive Resident Centered Care Plan, F-657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.25 Accident Hazards/Supervision, F-689 Free of Accident Hazards/Supervision/Devices at S/S of J and 42 CFR 483.70 Administration, F-835 Administration at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F-600 Free from Abuse and Neglect, F-607 Develop/Implement Abuse/Neglect, etc. Policies, F-610 Investigation of Abuse and 42 CFR 483.25, F-689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 09/24/2021. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021, alleging removal of the Immediate Jeopardy on 09/28/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 09/28/2021, as alleged, prior to exit on 10/07/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Close Observations; One (1) to One (1) Supervision; 15 Minute Checks, revised 02/22/2013, revealed the facility would provide the safest environment possible and/or prevent injury for all residents. Continued review revealed Close Observation was defined as within sight at all times; One (1) to One (1) Supervision was defined as in sight and reach at all times; and Fifteen (15) Minute Checks was defined as actual visualization at least every fifteen (15) minutes. Per policy, the above would be initiated as needed for a number of reasons, i.e., agitation, unpredictable or aggressive behaviors; after sedation; suicidal thoughts or threats; falls; or any time a resident's safety was an issue. Additionally, the Charge Nurse was responsible for assessing the Resident/situation and making the decision for the appropriate need (Close Observation; One {1} on One {1}; or Fifteen {15} Minute Checks). The Charge Nurse was also responsible to assign staff and explain what was expected of them and what they were to prevent. Continued review revealed a monitoring form would be started noting the resident's name, time initiated, and the appropriate need (Close Observation; One {1} on One {1}; or Fifteen {15} Minute Checks). Further, the resident/situation would be assessed every shift for the need to continue or resolve the increased supervision; documentation would be included in the medication record including the rationale. Continued review revealed communication to each on coming shift would be provided related to the increased supervision. The Physician and Responsible Party would be informed of the situation which required increased supervision. 1. Review of Resident #1's medical record revealed the facility admitted the resident, on 09/08/2017, with diagnoses which included Dementia without Behaviors Disturbances, [CONDITION(S)] due to substance or unknown psychological condition, Alzheimer's Disease, Pain Disorder, Major Depressive Disorder, Obsessive Compulsive Disorder, Anxiety Disorder, and High-Risk Heterosexual Behavior. Continued review of Resident #1's medical record revealed the resident had a POA. Review of Resident #1's Physician's Orders, revealed orders for [MEDICATION(S)] (antianxiety medication) 0.5 milligrams (mg) one time a day for Anxiety, with a start date of 03/16/2017; [MEDICATION(S)] (antianxiety medication) 12.5 mg two times a day for Anxiety, with a start date of 03/16/2017; psychiatry services to treat as indicated with a start date of 09/08/2017; [MEDICATION(S)] (acetylcholinesterase) 10 mg twice daily for dementia, with a start date of 09/08/2017; [MEDICATION(S)] (NMDA antagonist) 10 mg daily for dementia, with a start date of 09/11/2017; [MEDICATION(S)] (atypical antipsychotic) 50 mg at bedtime for [CONDITION(S)], with a start date of 05/09/2018 and Depo-[MEDICATION(S)] Suspension (hormone) 150 mg/ML daily for High-Risk Heterosexual Behaviors, with a start date of 08/05/2020. Review of Resident #1's Comprehensive Care Plan (CCP), dated 01/02/2019, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e., inappropriate touching or comments to female staff related to dementia with behaviors). The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; medicate as ordered; offer diversional activity; state to the resident stop sexual misconduct while immediately distancing resident to prevent harm from aggression, verbal praise the residents non-violent problem solving behaviors; and verbally confront the wrong doing or breech of another's personal rights and request future restraint/cessation of behavior, verbally praise compliance. Further review of Resident #1's CCP, dated 01/20/2021, revealed the resident had impaired cognition related to Alzheimer's Dementia and Panic Disorder. The goal was the resident would not show decline in cognitive function daily. Continued review revealed interventions that included but were not limited to: reduce distractions and negative environmental stimulus as much as possible; offer simple choices allowing sufficient time for decision making; allow the resident to discuss feelings or anger/powerlessness/frustration as needed. Interview with CNA #9, on 09/22/2021 at 12:30 PM, revealed Resident #1 had a history of behaviors such as touching staff's breast while they were providing care. Further, the resident was known to attempt to reach/touch female residents in the facility. Per interviews, staff tried to keep cognitively impaired residents away from Resident #1 because of his/her behaviors. Continued interview revealed she reported the behaviors to the nurses and was directed to keep an eye on the residents and to redirect Resident #1. Interview with CNA #6, on 09/22/2021 at 1:00 PM, revealed Resident #1 had a history of behaviors such as touching staff's breasts and butts and making sexual inappropriate comments to staff while they were providing care. Additionally, the resident was known to attempt to reach/touch female residents in the facility. Further staff attempted to distance other residents away from Resident #1 because of his/her behaviors. She reported the behaviors to nurses and was told to keep an eye on the residents, redirect Resident #1. Review of Resident #1's Mood and Behavior Patterns flowsheet, dated March 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness. Further review revealed no documented evidence of targeted behaviors Review of Resident #1's Progress Note, dated 03/08/2021 at 3:07 PM, written by Registered Nurse (RN) #2, revealed the resident was attempting to touch peers (other residents) without permission. Further, the Note stated the resident was redirected away from the area with frequent checks. However, there was no documented evidence the facility notified the POA or attending Physician. Review of Fifteen (15) Minute Checks, dated 03/08/2021 through 03/24/2021, revealed the resident was provided visualization from staff at least every fifteen (15) minutes. Review of Resident #1's Progress Note, dated 03/24/2021 at 2:14 PM, written by RN #2, revealed the resident was in the television room a few times throughout the day; one (1) time he/she required redirection due to reaching for female peer (resident). Additionally, the resident was reminded about respecting space and Resident #1 left the television area. Further, the POA and Physician were notified. Continued review of the medical record revealed Fifteen (15) Minute Checks were extended after the 03/24/2021 incident where Resident #1 attempted to reach for a female resident. Additional review revealed Fifteen (15) Minute Checks continued through 03/29/2021; the resident was provided visualization from staff at least every fifteen (15) minutes. Interview with RN #2, on 09/24/2021 at 11:20 AM, revealed Resident #1 had sexually inappropriate behaviors towards staff and would attempt to reach out and touch residents; however, he/she had never got another resident. Additionally, the resident wandered and got lost when attempting to find his/her room. Continued interview revealed she acknowledge the Close Observations; One (1) to One (1) Supervision; 15 Minute Checks policy, which discussed increased supervision of residents, and she utilized it as needed. Further, on 03/08/2021 when the resident attempted to touch another resident, she implemented the policy and initiated Fifteen (15) Minute Checks. Continued interview revealed on 03/24/2021, after the resident's second attempt to touch another resident she did not identify a need to increase supervision beyond Fifteen (15) Minute Checks because they were effective, and staff had caught the residents attempts and prevented the behavior of touching another resident. Review of Resident #1's Mood and Behavior Patterns flowsheet, dated April 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness. Further review revealed no documented evidence of targeted behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/21/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision of one (1) staff for transfers, ambulation, and locomotion with a walker. Review of Resident #1's Progress Note, dated 05/17/2021 at 4:00 PM, written by the Director of Nursing (DON), revealed the resident was involved in resident contact with another peer (resident). Additionally, no injury was noted, and the resident and peer (resident) were immediately separated. Further, the Medical Director (MD) and POA were notified. Additional review of Resident #1's Progress Note, dated 05/17/2021 at 4:30 PM, written by the DON, revealed the resident remained with staff until his/her room change was completed. Additionally, the room change was completed at that time. Further, the resident was assisted to the new room and introduced to his/her roommates, oriented to the room and the call light. Continued review revealed the POA was aware of the room move and was in agreement. However, review of Resident #1's Mood and Behavior Patterns flowsheet, dated May 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness. Further review revealed no documented evidence of targeted behaviors. Review of fifteen (15) Minute Checks, dated 05/17/2021, revealed on 05/17/2021 at 4:00 PM, Resident #1 was on one (1) to one (1) supervision until 4:30 pm; thirty (30) minutes. There was no further documented evidence of increased supervision for Resident #1. Additional review of Resident #1's Mood and Behavior Patterns flowsheet, dated May 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness. Additionally, on 05/23/2021 6:00 AM/6:00 PM shift, the resident was confused and went into the wrong rooms. Further review revealed on 05/30/2021 6:00 AM/6:00 PM shift, the resident was confused and wandered. Continued review of Resident #1's Mood and Behavior Patterns flowsheet, dated June 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness. Additionally, on 06/06/2021 6:00 AM/6:00 PM shift, the resident was confused and wandered into other rooms. Further review of Resident #1's Mood and Behavior Patterns flowsheet, dated July 2021 through September 2021, revealed targeted behaviors included social inappropriateness and sexual obsessiveness; however, there were no documented evidence of targeted behaviors. 2. Review of Resident #2's medical record revealed the facility admitted the resident, on 03/04/2020, with diagnoses which included Alzheimer's Dementia, Dementia with Behavioral Disturbance and Mood Affect Disorder. Continued review of Resident #2's medical record revealed a court ordered full time/permanent State Guardian was appointed to Resident #2 for medical and financial affairs, on 09/30/2019. Review of Resident #2's Physician's Orders, revealed orders for Trazadone (antidepressant medication) 50 mg at bedtime for Depression, with a start date of 03/04/2020; [MEDICATION(S)] (antidepressant medication) 20 mg one times a day for Depression, with a start date of 03/04/2020 and an end date of 05/18/2021; [MEDICATION(S)] Delayed Release 250 mg at bedtime for mood stabilization, Dementia, and Depression, with a start date 0f 03/04/2020; Psychiatry services to treat as indicated with a start date of 03/04/2020; [MEDICATION(S)] (antidepressant medication) 40 mg one time a day for High-Risk Heterosexual Behavior, with a start dated of 05/18/2021; [MEDICATION(S)] Delayed Release 125 mg one time a day for Mood affect, with a start date of 06/08/2021; and [MEDICATION(S)] (antidepressant medication) 40 mg, one time a day for High-Risk Heterosexual Behavior, with a start date of 06/09/2021. Review of Resident #2's Quarterly MDS Assessment, dated 02/02/2021, revealed the facility assessed the resident as having a BIMS score of four (4) out of fifteen (15), indicating severely impaired cognition. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to required supervision to limited assistance of one (1) staff for transfers, ambulation, and locomotion with a wheelchair. Review of Resident #2's CCP, dated 03/05/2020, revealed the resident had impaired cognition related to Alzheimer's Dementia. The goal was the resident would be able to make needs known daily. Continued review revealed interventions that included but were not limited to: allow time for the resident to express self, do no rush, anticipate needs; allow the resident to express feelings of anger/powerlessness and frustration; avoid commands like don't and no; offer simple choices; and reduce distractions and negative environment. Continued review of Resident #2's CCP, dated 09/28/2020, revealed the resident exhibited socially inappropriate/disruptive behaviors (i.e., inappropriate sexual comments) related to Dementia with behaviors. The goal was the resident would demonstrate reduced episodes of socially inappropriate/disruptive behaviors. Continued review revealed interventions included but were not limited to: attempt to discover and treat cause; do not reward undesirable behavior with extra attention of tendering loving care; and offer diversional activities. Additionally the CCP was revised on 05/13/2021, to include exposing genitals as an example of inappropriate/disruptive behaviors. Review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed On 05/13/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior not directed at other in the television room. Staff redirected the resident to his/her room, closed the curtain and door. Review of Resident #2's Progress Note, dated 05/13/2021 at 7:05 AM, written by the DON, revealed the resident was observed in the television room and had removed his/her brief exposing his/her peri-area. Additionally, the resident was redirected and assisted with dressing. Continued review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on 05/14/2021 on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behavior, hunching in THE wheelchair, in the television room. Staff redirected the resident to his/her room. Further review of Resident #2's CCP, dated 05/14/2021, revealed the resident exhibited social inappropriate behavior as evidence by masturbating in non-private areas. The intervention was to redirect/assist the resident to a room and reiterate the need for privacy (close door, draw curtain) when performing self-pleasure. Additional review of Resident #2's Mood and Behavior Patterns flowsheet, dated May 2021, revealed on the weekend of 05/15/2021 and 05/16/2021, on the 6:00 AM/2:00 PM shift, the resident exhibited sexual inappropriate behaviors. Staff provided verbal cues. Interview with CNA #9 on 09/22/2021 at 12:30 PM and CNA #6, on 09/22/2021 at 1:00 PM revealed Resident #2 had a history of behaviors such as touching staff's butts and goosing them while they were bent over near the resident. Additionally, the resident would make comments to staff; look at his/her butt, hey good looking, and try to whistle or call out. However, in the middle of May 2021, the resident's behaviors changed and were more frequent and had intensified. The CNAs reported the behaviors to nurses. The resident made foul and vulgar comments to staff, would touch his/her private body parts in commons areas, would undress in common areas, and hunch and grind on his/her wheelchair seat. Further, they were directed by nurses to redirect the resident and ensure his/her privacy was maintained. However, there was no documented evidence the CCP was revised to include sexual type behaviors: exposing his/herself in common areas, touching staff, grinding and hunching in the wheelchair, or vulgar comments directed towards others. Review of Resident #2's Progress Note, dated 05/17/2021 at 4:00 PM, written by the DON, revealed the resident was involved in resident contact with another peer (resident). Additionally, no distress was noted, and the resident and peer (resident) were immediately separated. Further, the Medical Director (MD) and POA were aware. Subsequently, per record review, on 05/17/2021, Resident #1 and Resident #2's were involved in an incident of sexual abuse. Review of Resident #1 and Resident #2's Incident Reports, dated 05/17/2021, completed by the DON, revealed an incident of resident contact occurred. Resident #1 and Resident #2 were confused and mobile with assistive devices. Per report, Resident #1 was observed in Resident #2's room with his/her hand resting on Resident #2's peritoneal area; Resident #2's clothing was pulled down. Continued review revealed the residents were separated and no distress was noted. Additionally, the residents were assessed with no injury(s). The Medical Director and POA were notified. Per reports, Resident #1 had a room change to decrease interaction with Resident #2, who was sexually seeking attention; Resident #1 and Resident #2 were placed on fifteen (15) minute checks. However, there was no documented evidence of fifteen (15) Minute Checks for Resident #1 after 05/17/2021 at 4:30 PM. Further Resident #2 had been noted with recent heightened sexual type behaviors: masturbation, exposing self, and vulgar comments directed towards staff. Interview with the Social Services Director (SSD), on 09/22/2021 at 5:06 PM, revealed she monitored Mood and Behavior Patterns flowsheet daily to establish patterns and interventions to meet resident needs. Per interview, the Interdisciplinary Team (IDT) {which included the Administrator, Minimum Data Set {MDS} Nurse, Therapy, Social Services, Unit Managers {UM}, and the Assistant Director of Nursing (ADON)), discussed the flowsheets each morning (Monday through Friday) and determine necessary actions to implement. Additionally, it was nursing's responsibility to immediately implement increased monitoring or supervision when behaviors were first observed or reported. Continued interview revealed the IDT's review ensured the most appropriate or more actions were implemented as necessary. Further, she had not identified any concerns or issues with the behavior flowsheets to being accurately documented. She was aware that Resident #1 had a history of inappropriate sexual behaviors, inappropriate comments towards others. However, she had never witnessed the behavior and had not seen the behavior documented for a long time on the behavior flowsheets. Per interview, Resident #2 had a history of inappropriate behaviors: sexual comments directed at others and masturbation. However, the IDT determine redirection was effective for the resident's increased frequency and change in behaviors on 05/13/2021 through 05/16/2021. On 05/17/2021, she was informed by the DON of the alleged sexual abuse between Resident #1 and Resident #2 and after review in IDT, on 05/17/2021, it was determined the most effective interventions to prevent or decrease reoccurrence was a room change for Resident #1; Fifteen (15) Minute Checks for Resident #2 and a medication review for both residents. Telephone interview with Resident #1's spouse and POA, on 09/24/2021 at 11:41 AM, revealed Resident #1 had admitted to the facility with a history of sexual behaviors directed towards others. Further, she expected the facility to provide necessary monitoring and supervision to all residents to ensure their safety and wellbeing. Interview with Resident #1 and Resident #2's Physician, on 09/24/2021 12:20 PM and the Medical Director, on 09/24/2021 at 6:40 PM, revealed they were aware of Resident #1 and Resident #2's behaviors. Additionally, they expected the facility to assess the resident's needs for increased supervision or monitoring as necessary. Further, residents with sexual behaviors directed towards others required increased supervision and monitoring to reduce and prevent further abuse. Telephone interview with the State Guardian for Resident #2, on 09/28/2021 at 3:45 PM, revealed she expected the facility to ensure residents were protected and not victimized or abused due to their impaired cognition. Additionally, she had not been informed of changes/increased sexual behavior starting on 05/13/2021; however, she would expect to be notified of changes in the resident's condition and for the resident to have adequate supervision provided to ensure his/her safety. Further, she had been informed by the DON on 05/17/2021 that Resident #2 had initiated and made sexual advanced towards another resident and she expect the resident and other residents had been provide adequate supervision to prevent further abuse. Interview with the DON, on 09/23/2021 at 1:05 PM, revealed she was aware that Resident #2 had intensified inappropriate sexual behaviors including masturbating in non-private areas and vulgar comments directed towards others since 05/13/2021; however, the IDT reviewed the behaviors and determined redirection alone was an effective intervention for the behaviors; therefore, she did not identify the need to increase monitoring or supervision for Resident #2 when his/her behaviors intensified. Per interview, Resident #1 had inappropriate sexual behaviors directed towards other; however, prior to the alleged sexual abuse on 05/17/2021 the resident had never wandered into other's rooms; therefore, she did not identify the need to increase supervision or monitoring after the resident's room was changed to another Unit. Additionally, the DON did not increase supervision of Resident #1 after his/her room change to another Unit because she believed Resident #2 instigated the incident and he/she was on fifteen (15) minute checks. The DON stated she expected all staff to provide adequate supervision while providing direct care to attempt to ensure resident safety was maintained and care needs were met. Further, if a resident was experiencing ongoing behaviors nurses were expected to assess and monitor the behaviors and implement interventions such as increased supervision per the facility policy to maintain resident safety. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed she expected staff to be aware and follow the facility's Close Observations; One (1) to One (1) Supervision; 15 Minute Checks, policy to the best of their ability. Additionally, she stated she expected residents to live in a safe environment. Per interview, it was important to the resident that there were limited opportunities for accident hazards, so they were cared for in a manner that provided safe individualized care. Further, the Administrator stated the facility did not fail because they implemented interventions after the resident contact was made to prevented further abuse. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/05/2021 that alleged removal of the Immediate Jeopardy (IJ) on 09/28/2021. Review of the AoC revealed the facility implemented the following: 1. (a) On 05/17/2021, Resident #1 was transferred to another unit within the facility away from the room of Resident #2. (b) On 09/24/2021 and on 09/27/2021, the Director of Nursing (DON) revised the care plan for Resident #1 to include the redirection for any observed sexual behaviors and provision of privacy. On 09/26/2021, the Minimum Data Set (MDS) Coordinators and the DON revised the care plan for Resident #1 to include constant one on one visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #1 was free from abuse. (c) On 09/24/2021, the DON reviewed the care plan for Resident #2 including the provision of privacy for any observed sexual behaviors and that privacy will be assured until the sexual behavior had concluded. On 09/26/2021, the MDS Coordinators and the DON revised the care plan for Resident #2 to include constant visual observation by employees who had been trained in the abuse prohibition policies of the facility to assure that Resident #2 was free from abuse. 2. (a) The Social Services Director (SSD) interviewed all interviewable residents on 09/24/2021 to solicit for any concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. These interviews were to be completed daily seven days a week by the SSD or assistant. (b) The Administrator mobilized the ReachAlert system, an automated communication system that can contact all staff, residents or their responsible parties by phone text or email, on 09/24/2021 to contact each employee and resident representative to solicit any resident concerns related to resident care and treatment within the facility to include abuse, neglect, and exploitation. (c) From 09/24/2021 through 09/25/2021, the DON and Charge Nurse completed physical observations including skin assessments of each resident to assure that residents were free from abuse and neglect. 3. (a) On 09/24/2021, the facility secured a long-term care consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. The LTCC provided education to the Administrator on 09/24/2021 and 09/25/2021 regarding the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents were free from abuse, neglect, and exploitation. The Administrator completed a post-test on 09/26/2021. The education provided by the LTCC was according to the Abuse Prohibition Policies of the facility. (b) On 09/24/2021, the LTCC started meeting daily with the Administrator to review the practices and outcomes of education provided to the administrator who passed on the education to management staff that included the DON and the SSD. The education included the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation and to provide daily guidance. (c) From 09/24/2021 through 09/27/2021, the SSD and the DON, who were trained by the Administrator, and a charge nurse trained by the DON on the prevention of abuse, implementing abuse policies, thorough and timely investigation of abuse, the role of timely assessment and revision of care plans for abuse, care plan implementation, immediate and adequate supervision and monitoring, and resident rights to assure that residents are free from abuse, neglect, and exploitation, provided education to all employees of the facility and agency staff. Freedom from abuse, neglect and exploitation and resident rights was included in the education and according to the facility policies on abuse prevention and implementation of the facility abuse prohibition policies. Each employee received a post-test from 09/24/2021 through 09/27/2021 after receiving the education. Employees and agency staff that were off work and unavailable to work for any reason will receive this education and post-test before returning to work. (d) From 09/24/2021 through 09/26/2021, the MDS Coordinators and the DON completed resident care plan reviews to provide updates, needed revisions and care plan implementation daily to address the assessed needs related to supervision and monitoring to ensure a safe environment and prevent sexual abuse. 4. Beginning on 09/24/2021, the Quality Assurance Committee (QAC) condu [TRUNCATED]

Based on observation, interview and review of facility's policy, it was determined the facility failed to keep food in a safe and sanitary environment as determined by observations of lunch meal trays. Observations on 09/21/2021 revealed lunch meals trays on an uncovered cart sitting outside the kitchen door and on the Arcadia and Railroad Units with bowls of food uncovered, Further observations revealed trays were delivered into resident rooms. The findings include: Review of the facility policy titled Food Handling and Safety, dated 05/02/2019, revealed all food items served to residents were prepared using methods and techniques that were designed to preserve maximum nutritive value, enhanced flavor and assure that what was served was free of injurious organisms and substances. Additionally, all food items, while in preparation, were protected against contamination from dust, flies, rodents, other vermin, unclean utensils, unclean work surfaces, unnecessary handling, coughs, sneezes, flooding, drainage, overhead leaks, and any other source of contaminant. Per review only authorized personnel were allowed in food preparation areas. Further, food was prepared and served with clean utensils and other suitable implements to minimize handling and to avoid manual contact with food at all points during preparation and services. Review of the facility policy titled Nutrient Retention of Food, undated, revealed the facility would serve food in such a manner as to conserve the nutritive value of food. Additionally, prepared food was transported to other areas in covered containers. Further, bare hands should never touch food directly; utensils, cups, and dishes were handled in a way to avoid touching surfaces that food or drinks would come in contact with. Observations of lunch meal services, on 09/21/2021 12:40 PM, revealed a full uncovered cart of meal trays unattended outside the kitchen door in a common hallway. Continued observation revealed the uncovered cart contained several meal trays with uncovered bowls. Additional observations, on 09/21/2021 at 12:46 PM, revealed the uncovered cart with trays was delivered to the Arcadia Unit. Further observations revealed meal trays with uncovered bowls were delivered into resident rooms for Resident #7, Resident #8, Resident #9, Resident #10 and Resident #11. Further observations, on 09/21/2021 at 12:55 PM revealed meal trays on the Arcadia Unit for Resident #5 and Resident #6 had uncovered bowls. Interview with Certified Nursing Assistant (CNA) #6 and CNA #8, on 09/21/2021 at 12:50 PM, revealed they did not notice that meal trays had uncovered bowls on them because they were nervous the State Survey Agency (SSA) was watching the meal service. Additional interview revealed all foods should be covered when they came out of the kitchen onto the floor. Per interview, covering foods kept them clean, safe and sanitary. Further, if food was not covered infection control was not maintained and it should not be served to residents, it should be sent back to the kitchen. Interview with Registered Nurse (RN) #1, on 09/21/2021 at 1:00 PM, revealed all food from the kitchen should be covered to reduce the potential for contamination. Further, she would send food back to the kitchen and have it replaced if she found it on a meal cart/tray uncovered; she would not serve the food to residents. Interview with Dietary Aide #1, on 09/21/2021 on 1:05 PM, revealed kitchen staff ensured food was covered before it left the kitchen. Per interview, food could be covered with plastic wrap or lids. Additional interview revealed foods were covered to ensure debris did not get into the food. Further, he had been provided infection control training on safe food handling. Interview with Cook #1, Cook #2 and Cook #3, on 09/21/2021 at 1:10 PM, revealed they had been provided training from the facility on Safe Food Handling, which included covering all foods out of the kitchen. Additionally, they had plastic lids and plastic wrap in the kitchen for covering bowls. Continued interview revealed they were not aware of food in bowls leaving the kitchen uncovered for lunch meal service. Further, leaving food uncovered was an infection control problem and there was potential for foods to become contaminated and make the residents sick. The Dietary Manager (DM), was not available for interview on 09/21/2021. Interview with Director of Nursing (DON), on 09/23/2021 at 1:05 PM, revealed she expected food served to be sanitary food. Per interview, she expected safe food handling to be maintained per the facility's policy and protocols. Additionally she expected food to be covered at all times when it came out of kitchen to travel anywhere in building. Further, she expect nursing staff not to server uncovered food to residents. Continued interview revealed it was important to maintain sanitary food and ensure food was covered to ensure infection control and decrease risk of food borne illness or contamination. Interview with Administrator, on 09/24/2021 at 5:00 PM, revealed her expectations for safe food handling was that food would be covered when it came out of the kitchen per the facility's policy. Per interview, she also expected nursing staff not to deliver uncovered food to residents. Further she stated it was important that food outside the kitchen was covered to decrease the risk for food borne illnesses. a

Based on observation, interview, medical record review, and review of the facility's Resident Rights document, it was determined the facility failed to ensure each resident was treated with respect and dignity and care provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the residents for one (1) of fifteen (15) residents; Resident #4. Observations, on 09/22/2021 at 9:02 AM, by the State Survey Agency (SSA) Surveyor of Resident #4 revealed the resident was lying in bed and Certified Nursing Assistant (CNA) #4 standing hovering over the patient at the bedside assisting the resident with his/her breakfast meal. The findings include: Review of the facility's Resident Rights document, dated 04/27/2021, revealed the facility's goal was to provide quality healthcare to all residents. Additional review of the policy revealed residents would be treated with respect and dignity while providing resident care that was necessary and appropriately allow each resident to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Continued review revealed residents would be treated in a manner that preserved their dignity and self-esteem. Further, Resident Rights, as stated by Federal and State mandates, would be honored in the facility; Residents had the right to live with dignity and to be treated with respect. Review of Resident #4's medical record revealed the facility readmitted the resident, on 09/14/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, dated 06/25/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severely impaired cognition. Further review of the MDS Assessment revealed the facility assessed the resident to require limited assistance of one (1) staff for eating. Review of Resident #4's Comprehensive Care Plan (CCP), revised on 09/15/2021, revealed the resident was in need of comfort measure related to Adult Failure to Thrive. The goal was the resident's needs would be met, and he/she would be kept comfortable and pain free. The interventions included: assist with grieving process by allowing the resident to express concerns/fears; diet as ordered; and provide psychosocial support as needed. Observation of Resident #4, on 09/22/2021 at 9:02 AM, revealed CNA #4 enter the resident's room to assist the resident with his/her breakfast meal. Additional observation revealed the resident was lying in bed in a semi-fowlers position and the bed below knee height. The resident was awake and was dependent for eating. Further observations revealed the CNA stood at bedside and assisted the resident with cups of liquid until 9:20 AM. Interview with CNA #4, on 09/22/2021 at 10:00 AM, revealed she had worked at the facility for five (5) years. Per the interview, she had been provided Resident Rights training by the facility. Additionally, she stated she usually would sit at eye level with the residents while she was providing assistance with their meals; however, Resident #4 was in isolation and there was not a chair for her to sit in, in his/her room. Per interview she should have asked another staff member to get a chair for her to sit in. Further, she stated she was aware she should have been seated at eye level to ensure Resident Rights of dignity to the resident and to be respectful and not stand over him/her. Interview with Registered Nurse (RN) #1, on 09/22/2021 at 2:54 PM, revealed she was aware of Resident Rights to include dignity. Additionally, she stated all staff should ensure Resident Rights while providing care. Additional interview revealed she would continuously round on the hallways and watch the resident care; however, today she was passing meal trays and did not notice CNA #4 was standing while she assisted Resident #4 with his/her meal. Further, she stated it was not acceptable that CNA #4 stood while she assisted the resident with his/her meal. Interview with the Director of Nursing (DON), on 09/23/2021 at 1:05 PM, revealed she expected all staff to maintain Resident Rights. Per interview, residents and staff were educated on Resident Rights at least annually and should be familiar with them and how to uphold them. The DON further stated staff should understand and provide Resident Rights with all care to ensure residents were provide care in a dignified manner. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed she expected Resident Rights to be honored. Additionally, she stated she expected staff to make every effort to ensure dignity, as required in the facility's Resident Rights. The Administrator further stated it was important that staff to sit at eye level and engage with residents during meal services and not stand over residents when assisting with meals.

Based on interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. The facility failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, on 09/22/2021, revealed improper use of Personal Protective Equipment (PPE) in a Droplet Precaution isolation room for one (1) of fifteen (15) residents, Residents #4. The findings include: Review of the facility's policy titled, Precautions for Managing Infection, dated 10/04/2017, revealed the purpose of the policy was to decrease and/or prevent the spread of infectious disease through the use of Standard Precautions, Transmission-based Precautions, and resident placement during care of all residents based on regulation. Additionally, the policy would be utilized during the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Per policy, Standard Precautions include hand hygiene, use of gloves, use of masks, eye protection, face-shields, and use of gowns. Continued review revealed Masks, Eye Protection and Face-shields were to be worn for protection during procedures and resident-care that was likely to generate body fluids, secretions and excretions. Further, donning and doffing of PPE should be performed in a manner that prevents contamination and transmission of microorganisms. Donning sequence: apply gown, apply mask, apply goggles or face-shield, and apply gloves. Doffing sequence: Remove gloves, removes goggles or face-shield, remove gown, remove mask, and perform hand hygiene. Review of the facility's policy titled, Precautions for Managing Infection; Transmission-Based Precautions, dated 10/04/2017, revealed in addition to Standard Precautions, Transmission-Based Precautions (TBP) would be used for residents documented or suspected to be infected with highly transmissible pathogens when additional precautions were needed to interrupt transmission or infectious disease. Additional review revealed Contact Precautions were implemented when transmission of disease could occur through direct or indirect contact and in addition to Standard Precautions the following would be required: placement in a private room or cohort with similar infection; dedicated use of resident care equipment; red bio-hazard bags for disposal of contaminated material. Further review revealed Droplet Precautions were implemented when transmission of disease involved the contact of the eyes or mucous membrane of the nose or mouth of a susceptible person with large particle droplets containing microorganisms generated from coughing, sneezing, talking, suctioning or other similar activities. In addition to Standard Precautions the following would be required for a resident in Droplet Precautions: placement in a private room or cohort with similar infection; mask worn within three (3) feet of the resident. Review of the CDC's website (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ), Isolation Precautions, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, IV.B. Personal Protective Equipment (PPE), last updated 07/22/2019, revealed, in healthcare settings PPE, should be worn when anticipated patient interaction indicated contact with blood or body fluids. Additionally, PPE should be removed and discarded before leaving the patient's room to prevent contamination of clothing and skin. Further, a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles should be worn. Review of CDC's website (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_ ), Transmission-Based Precautions, Droplet Precautions, last review 01/07/2016, revealed before entering a residents room, eyes, nose and mouth should be fully covered. Further, face protection should be removed before exiting the room. Review of the facility's policy titled, Personal Protective Equipment (PPE), undated, revealed the facility would provide employees with sufficient number of face mask which must be changed at least once a day, whenever they were soiled or damaged, and more frequently as necessary with patient care reasons. Additionally, employees would be instructed on donning and doffing PPE on hire and annually. Further, the facility would provide N-95 mask and other PPE for suspected or confirmed COVID-19 per regulation. Review of Resident #4's medical record revealed the facility readmitted the resident, on 09/14/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Comprehensive Care Plan (CCP), dated 01/18/2021, revealed the resident was at risk for active psychosocial well-being related to restriction secondary to COVID-19. The goal was the resident would not show a decline in well-being or experience adverse effects. The interventions included assure the resident and facility were using necessary precautions and provide COVID-19 testing as indicated. Review of Resident #4's Progress Note, dated 09/14/2021 at 9:30 AM, revealed the resident was readmitted to the facility from an acute care hospital with comfort care services. Observations, on 09/22/2021 at 9:02 AM, of the Railroad Unit, revealed Resident #4 had a sign on the door See nurse before entering, and a freestanding cart to the right side of the doorway with PPE supplies. Supplies available in the PPE cart included hand sanitizer, Lysol spray, SANI wipes, goggles, gloves, gowns, trash bags and bio hazard bags. There were no mask in the PPE supply cart. Additional observation revealed Certified Nursing Assistant (CNA) #4 wearing a surgical mask. CNA #4 stood outside the resident's door and donned a gown, and gloves; she did not don eye protection (goggles) before she entered the room. Additional observations revealed CNA #4 assisted the resident with washing his/her face with a wet wash cloth and eating breakfast. CNA #4 was observed touching and readjusting her surgical mask with her gloved hands. Further observations revealed at 9:20 AM, CNA #4 exited Resident #4's room; however, she did not doff the surgical mask worn in the resident's room. Further observations revealed CNA #4 walked up the hallway, through a common area and into the kitchen with the surgical mask worn in the resident's room. Interview with CNA #4, on 09/22/2021 at 10:00 AM, revealed she had been provided training on Infection Control including COVID-19 (how it was spread), PPE (appropriate use), and what PPE to wear in TBPs. Additional interview revealed Resident Rights training by the facility at this time revealed A Wing isolation rooms were for newly admitted residents who had respiratory concerns or had a laboratory confirmed illness that required TBP. Per the interview, Droplet Precautions required a gown, eye protection, a mask, and gloves when providing care for the resident. CNA #4 stated the reason she was not wearing eye protection, when she provided assistance to residents was because she was nervous the SSA was watching and forgot to get goggles out of the PPE cart. However, she stated it was important to protect ourselves, families, and other residents with infection control practices and she should have worn goggles in the resident's room. Further, she was not sure if she should have changed her surgical mask before entering the resident's room to another mask, or if she should have removed her mask when she exited the room and changed it to another mask; however, she should have asked the nurse what to do to ensure infection control guidelines were followed. Interview with the Director of Nursing (DON), on 09/22/2021 at 9:35 AM, revealed the facility did not have any shortage of PPE, including masks. Per interview, there were no positive COVID-19 residents in the facility and staff wore dedicated surgical mask in the facility each day. Further staff were issued a new clean surgical mask every day and supplies of mask were available as needed. Interview with the Assistant Director of Nursing (ADON) and Infection Preventionist (IP), on 09/22/2021 at 11:23 AM, revealed she had worked at the facility for five (5) years and was responsible for Infection Control efforts in the facility. Per the interview, staff wore dedicated PPE, a mask, at all times in the facility. Continued interview revealed Resident #4 was on Droplet Precautions, and staff should always have on PPE to include: eye protection, mask, gown, and gloves, when provided his/her care. Additionally, she stated appropriate use of PPE was important to avoid contracting and spreading COVID or any infectious disease. She stated improper use of PPE would increase the risk for cross contamination, and she expected the facility's policy and CDC guidelines to be followed at all times. Further, at no time should staff members be in a Droplet Precaution resident room and not be wearing eye protection and staff should not wear contaminated PPE outside of TBP rooms. Continued interview revealed isolations rooms should have appropriate PPE available at the door and appropriate notification should be placed on the door so that personnel and visitors were aware of what precaution(s) were necessary. She stated staff should change surgical masks when entering and exiting TBP rooms to reduce the risk for cross contamination. She also stated PPE should be donned before entering an isolation room. Interview with the Director of Nursing (DON), on 09/01/2021 at 10:26 AM, revealed she expected facility policies related to infection control and CDC Guidelines to be maintained by all staff. Additionally, she expected staff to wear eye protection when providing care to residents in Droplet Precautions. Per the interview, staff were trained to know what PPE they should wear in the resident's room for TBPs. It was important for staff to know what PPE to wear for the different types of isolation, so the right PPE was worn to decrease risk for infection and cross contamination. Further, she stated PPE should be doffed in the isolation room. CNA #4 should have removed their face masks upon exiting Resident #4's room. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed they expected staff to follow Infection Control guidelines (CDC and regulatory). Per the interview, they ensured Infection Control practices were maintained through audit practices in the building, utilizing observations, tracking, and trending. Additionally, she expected PPE guidelines to be followed as well as appropriate use of PPE for TBP's, specific to the isolation type. Further she expected PPE to be removed before exiting an isolation room. She stated all these infection control practices were important to prevent transmission of disease.

Based on interview, record review, review of the facility's policy, and review of the Kentucky Revised Statutes (KRS) Chapter 209.030, it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse, to the Administrator of the facility and to State Agencies for one (1) of fifteen (15) residents Resident #3. Review of Resident #3's Incident Report, dated 05/18/2021 at 7:15 AM, revealed he/she kissed Resident #1 on the lips; the Director of Nursing (DON), reported the incident to the Administrator. Review of the email confirmation of the Allegation Report and Investigation, dated 05/18/2021, revealed at 10:01 AM, the resident-to-resident allegation or incident was reported; approximately three (3) hours after the allegation of abuse. The facility failed to report the incident to State Agencies within two (2) hours. The findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation, review date 07/07/2020, revealed that one (1) of the seven (7) components to ensure residents were free from abuse included reporting/response. Further review of the policy revealed an investigation would be performed to determine if abuse occurred; a thorough assessment would be completed for the resident(s) and the Responsible Party/Guardian, Attending Physician, the Department of Community Based Services (DCBS) and the Division of Long-Term Care would be notified within two (2) hours. Additional review of the facility's policy, Abuse, Neglect, and Exploitation, dated reviewed on 07/07/2020, revealed the facility mandated that the right of individuals to be protected as outlined in the state and federal regulation and staff were responsible for the health, safety and welfare of all residents. Further, Abuse, including sexual abuse, was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; Willful was define as deliberate action, not that the individual intended to inflict injury or harm; and Sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with residents. Review of KRS Chapter 209.030 revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. 1. Review of Resident #3's medical record revealed the facility admitted the resident, on 10/11/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the resident had a Power of Attorney (POA). Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 03/23/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating intact cognitive response. Additional review of the MDS Assessment revealed the facility assessed the resident under Section E, as having no physical behavioral symptoms directed towards others. Further review of the MDS Assessment, revealed the resident was assessed to require extensive assistance of one (1) staff for transfers, ambulation and locomotion with a wheelchair. Review of Resident #3's Progress Note, dated 05/18/2021 at 7:15 AM, written by the DON, revealed the resident was involved in resident contact with another peer (resident). Additionally, the Medical Director (MD) and POA were notified. Further, the resident was placed on fifteen (15) minutes checks. Review of Resident #3's Incident Report, dated 05/18/2021 at 7:15 AM, written by the DON, revealed Resident #1 was sitting in the television room and Resident #3 rolled his/her wheelchair up to the resident and kissed them on the lips. Additional review revealed Resident #3 stated he/she kissed their spouse. Continued review revealed Certified Nursing Assistant (CNA) #11 witnessed the incident. Per Report, Resident #3 was placed on fifteen (15) minute checks. Further, the MD and POA were notified. Review of the facility's Initial and Final Allegation Report and Investigation, which was e-mailed to the Office of Inspector General (OIG- State Survey Agency), on 05/18/2021 at 10:01 AM, signed by the Administrator, revealed a resident-to-resident incident or allegation had occurred between Resident #1 and Resident #3. The Legal Representative, the Physician, Adult Protective Services (APS) and OIG were notified of the alleged incident on 05/18/2021 at 10:01 AM. Per the report, review of the resident's history, revealed Resident #1 was diagnosed with Heterosexual behavior, Alzheimer's Disease, Panic Disorder, history of Alcohol Abuse and had a BIMS score (Brief Interview of Mental Status) score of six (6) out of fifteen (15). Per Report, Resident #3 was diagnosed with Dementia, Extrapyramidal Movement Disorder, Explosive Disorder and had a BIMS score of four (4). Review of the Description of Allegation or Incident revealed Resident #3 was observed in the dining room rolled his/her wheelchair over to Resident #1 and kiss the resident. Further review revealed actions taken to protect resident(s) included immediate separation and Resident #3 was placed on fifteen (15) minute checks. Per Report, no abuse or intent to harm was established. Continued review of the Initial and Final Allegation Report and Investigation, dated 05/18/2021, revealed Resident #1 stated he/she did not know what happened. Per Investigation, Resident #3 stated he/she kissed their spouse good morning. Additionally, an employee Interview with Certified Nursing Assistant (CNA) #11, revealed Resident #3 rolled his/her wheelchair over to Resident #1 in the dining room and kissed the resident. Additional Findings of the Investigation revealed both residents were confused. Continued review revealed the residents were separated and Resident #3 was placed on fifteen (15) minute checks; Registered Nurse (RN) #1 was notified. Both residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Legal Representatives and the Physicians were notified. Review of CNA #11's witness statement, dated 05/18/2021, revealed while in the television room, she saw Resident #3 roll over to Resident #1 and kiss him/her on the lips. Additionally, Resident #1 did not respond to the kiss. Further, the CNA separated the residents and reported immediately to RN #1. SSA attempted to contact CNA #11, on 09/24/2021 at 12:15 PM. Interview with RN #1, on 09/22/2021 at 2:54 PM, revealed she had worked on the Arcadia Unit on 05/18/2021 from 6:00 AM/6:00 PM shift. Per interview, she recalled the incident between Resident #3 and Resident #1 that occurred on 05/18/2021. Additionally, after review of Resident #3's medical record, on 05/18/2021, she recalled reporting the incident to the DON. Further, administration was responsible for reporting allegation of abuse to State Agencies. Interview with the Director of Nursing (DON), on 09/23/2021 at 1:05 PM, revealed on 05/18/2021 at approximately 7:00 AM, she was notified by RN #1, that Resident #3 had rolled his/her wheelchair up to Resident #1 in the dining room and kissed the resident on the lips. Per interview, she initiated an investigation, and the residents were immediately separated. Additionally, she reported the incident to the Administrator. The DON stated the allegation of sexual abuse between Resident #1 and Resident #3 was not abuse because both residents were cognitively impaired. Further, the facility's policy and procedure on abuse were followed. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed she reported all incidents she felt were abuse, within 2 hours to State Agencies, per regulatory timeframes. Per interview, the alleged abuse on 05/18/2021 for Resident #1 and Resident #3 was witnessed by staff in the facility and the investigation determined there was no harm or intent. The Root Cause was determined to be impaired cognition; therefore, abuse did not occur. Further, the facility policy related to abuse and reporting was followed.

Based on observation, interviews, review of the facility's policies, review of the Centers for Disease Control and Prevention (CDC) website on COVID-19 Strategies for Optimizing the Supply of Eye Protection and Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, it was determined the facility failed to conduct COVID-19 testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests. Observation, on 09/22/2021 at 12:13 PM, revealed Registered Nurse (RN) #4 obtain a COVID-19 specimen from two (2) staff; however, she failed to clean/disinfect her face-shield after handling a contaminated test specimen/in between staff. The findings include: Review of the facility's policy titled, Precautions for Managing Infection, dated 10/04/2017, revealed the purpose of the policy was to prevent the transmission of infectious organisms by use of standard precautions. Additional review of the policy revealed standard precautions would be used when caring for residents at all times regardless of their suspected or confirmed infection status. Continued review revealed in addition to standard precautions, the policy stated staff would wear appropriate PPE as a barrier to exposure, including eye protection. Further review revealed donning and doffing of PPE should be performed in a manner that prevented contamination and transmissions of microorganisms. Review of the CDC's website (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html#handling-specimens-safely) on COVID-19 Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, last revised 02/26/2021, revealed, for healthcare providers collecting specimens should maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator, eye protection, gloves, and a gown. Review of the CDC's website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html ) on COVID-19 Strategies for Optimizing the Supply of Eye Protection, last updated 09/13/2021, revealed, in healthcare settings, eye protection was used by Health Care Professionals to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions. Additionally, disposable eye protection should be removed and discarded after use. Further, reusable eye protection should cleaned and disinfected after each patient encounter. Observation, on 09/22/2021 at 12:13 PM, revealed RN #4 obtain an COVID-19 specimen from the Director of Nursing (DON). After doffing her face-shield she failed to clean/disinfect the eye protection and sat it on the counter top while she prepared for testing of a second employee. However, when she donned her PPE for the second collection of an COVID-19 specimen, she failed to clean/disinfect her face-shield before donning. Further, RN #4 proceeded to obtain the COVID-19 specimen from Dietary #2 while wearing the contaminated face shield. Interview with Registered Nurse (RN) #4, on 07/28/2021 at 11:56 AM, revealed she acknowledged CDC Guidelines and the facility policy should be maintained for current standards of practice for handling specimens and PPE. Continued interview revealed on 09/22/2021, while collecting COVID-19 employee specimens she should have wiped down the face-shield with Clorox wipes in between testing each employee. Further, it was important to clean/disinfect reusable eye protection after each employee to decrease the risk of cross contamination and the potential spread of infection disease to others. Interview with the Assistant Director of Nursing (ADON), on 09/22/2021 at 3:30 PM, revealed she was the facility's Infection Preventionist and was responsible for the infection control program at the facility. Additional interview revealed she monitored the employee COVID-19 testing and had not identified any concerns with handling specimen collection and/or PPE. Continued interview revealed the room was equipped with testing supplies, PPE, and supplies for cleaning reusable PPE. Further she stated RN #4 was trained to perform COVID-19 test. Per interview, she stated staff were required to follow Standard Precautions for Infection Prevention and Control, included cleaning/disinfection reusable PPE (face-shields) after testing and handling contaminated test cards. Per the interview, RN #4 should have clean her face-shield in between testing two (2) employees. Interview with the DON, on 09/22/2021 at 3:42 PM, revealed employee COVID-19 testing should be performed per current standards of practice related to handling specimens and proper use of PPE. Additionally, RN #4 should have cleaned her face-shield between testing employees. Further, she stated she expected staff would wear appropriate PPE in a manner that would prevented contamination and transmissions of microorganisms. Interview with the Administrator, on 09/24/2021 at 5:00 PM, revealed she expected all staff to follow the CDC and facility's policy(s) on Infection Control and Prevention. Additionally she expected PPE guidelines to be followed during COVID-19 testing and Reusable PPE to be cleaned in between obtaining samples. Further, it was important that infection control was maintained to prevent an outbreak of infection disease and the spread of illness.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain sanitary conditions related to dirty, soiled kitchen floors. Observation revealed the kitchen floor was not clean with black soiled marks on the floor as the base of the entrance doorway; and, black areas and dust particles to the floor to the left of the steam table and beside the hot water heater. The findings include: Review of facility policy titled, Food preparation and Handling, not dated, revealed the kitchen and equipment are to be clean and the kitchen to be neat and orderly. Observation of the kitchen floor, on 03/23/2021 at 12:14 PM, revealed there were black, soiled marks on the floors at the entrance door to the kitchen at the bottom where the door frame meets the door at the floor. In addition, there were black areas to various areas of flooring in the kitchen to include to the left of the steam table which also had dust particles, and was beside the hot water tank. Interview with the Dietary Director, on 03/25/21 at 2:15 PM revealed the kitchen floors were cleaned every night. She stated she was not aware of the soiled floor to the left of the steam table nor at the base of the entry door to the kitchen. Interview with the Administrator on 03/25/2021 at 3:30 PM revealed she was aware of the concerns regarding the floors in the kitchen.

Based on observation, interview, record review, and facility Protocol review, it was determined the facility failed to ensure that one (1) of one (1) residents in the facility with an indwelling urinary catheter (Resident #50) received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION]. Observations on 03/24/2021 revealed Resident #50's urinary catheter drainage bag was on the floor. Observation of State Registered Nursing Assistant (SRNA) #1 at 1:41 PM on 03/24/2021 revealed the SRNA picked the catheter bag up off the floor, moved it closer to the resident, but put it back on the floor without ensuring the catheter bag was maintained off the floor to prevent UTIs. The findings include: Review of the facility policy titled Foley Catheter Protocol, revised 02/04/2014 revealed SRNAs were to check residents with an indwelling catheter every two (2) hours to ensure the catheter bag was maintained off the floor. Record review revealed the facility admitted Resident #50 on 12/03/2020 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) Assessment with a reference date of 12/10/2020 revealed the resident had an indwelling urinary catheter on admission. Review of the most recent physician's orders, revealed an order for [REDACTED]. Further review of the record revealed a care plan for the risk of infection related to the use of an indwelling catheter, dated 12/16/2020, revealed interventions to include for the resident to utilize a bedside drainage bag at night and a leg drainage bag while out of bed. The care plan was revised on 03/24/2021 to include an intervention that it was acceptable to utilize the bedside drainage bag temporarily when a leg drainage bag was not available. Further review of the resident's medical record revealed [REDACTED]. Observations of Resident #50 on 03/23/2021 at 10:06 AM, 1:20 PM, and 4:50 PM, revealed the resident moved from the chair to the bed independently in the room and was utilizing a urinary leg drainage bag for the indwelling catheter. Observations on 03/24/2021 at 10:45 AM revealed the resident was sitting on the bed with a bedside drainage bag lying on the floor beside the bed. Further observation of Resident #50 on 03/24/2021 at 12:05 PM revealed the resident was sitting in a chair at the counter in his/her room with the bedside drainage bag hanging on the chair. At 1:28 PM on 03/24/2021, Resident #50 was feeding him/herself lunch with the urinary catheter drainage bag noted lying on the floor next to the chair. On 03/24/2021 at 1:39 PM, Resident #50 transferred himself/herself from the chair back to the bed with the catheter bag remaining on the floor. SRNA #1 was observed to enter the resident's room at 1:41 PM, clean the resident's face, and pick up the catheter drainage bag and move it closer to the bed; but put the catheter drainage bag back on the floor. SRNA #1 then took the resident's lunch tray and left the room. At 1:46 PM on 03/24/2021, SRNA #2 entered Resident #50's room and picked the catheter drainage bag up off the floor and hung it on the bed frame. Observation of Resident #50 on 3/24/2021 at 4:40 PM revealed the resident was utilizing a leg bag instead of the bedside drainage bag. Interview with SRNA #2, on 03/24/2021 at 1:50 PM revealed she noticed Resident #50's catheter bag on the floor and picked it up because catheter bags are not to be left on the floor. She further stated that she had asked about the leg drainage bag for Resident #50 and was told that there were no leg bags available that day and that was why the resident did not have a leg bag in place. Interview with SRNA #1, on 03/24/2021 at 2:01 PM revealed she was the SRNA assigned for Resident #50 that day. She stated when she entered Resident #50's room and saw the urinary drainage bag lying on the floor, she forgot to move it off the floor because Resident #50 usually had a leg drainage bag and she just didn't think about it. She stated when she got Resident #50 up this morning, she could not find a leg drainage bag and reported it to the nurse. Interview with Licensed Practical Nurse (LPN) #1 on 03/24/2021 at 4:40 PM revealed SRNA #1 reported to her that they did not have a leg urinary drainage bag for Resident #50 that morning. She stated she spoke with the supply person and they got one as soon as possible. LPN #1 stated that all staff were trained to maintain catheter bags off the floor to prevent urinary tract infections. Interview with the Director of Nursing (DON), on 03/26/2021 at 9:54 AM revealed the facility expected all staff to ensure catheter bags were maintained off the floor due to the risk for infection if a catheter bag was on the floor. The DON further stated that care audits were done on a daily basis through daily rounds and she had not identified this to be a concern.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions. Observation of two (2) of four (4) medication carts revealed one (1) cart had 2 boxes of expired medications. The findings include: Review of the facility policy titled. Medication Storage, dated 08/17/2017, revealed medications will be dated at time of opening as appropriate (ie. Insulin, TB Solution, etc.). Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, unlabeled or without secure closures are immediately removed from stock, and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. Observation of Medication Cart #1 on 03/25/2021 at 11:15 AM, revealed the following expired medications: [REDACTED] Resident #45 - [MEDICATION NAME] 100 milligrams (mg) capsules - fourteen (14) capsules with an expiration date of 06/27/2020. Resident #22 - [MEDICATION NAME] 100 mg capsules - twenty-seven (27) capsules with an expiration date of 10/29/2020. Interview with Director of Nursing (DON) on 3/25/2021 at 11:15 AM revealed she expected nurses and medication techs to check the carts daily and remove any expired medications. The DON further stated she and the Assistant Director of Nursing (ADON) randomly checked carts but revealed she had no documentation of audits. She revealed Pharmacy typically completed monthly reviews but had not been in the building since the pandemic started

Based on interview, record review, and facility policy review, it was determined the facility failed to provide two of of three (3) sampled residents' Guardians and Ombudsman with a written notice of discharge as soon as practicable (Residents #1 and #3). The findings include: Review of the facility policy titled, Transfer/Discharge, not dated, revealed residents will be allowed to remain in the facility unless criteria for transfer or discharge is met. Under the section titled Procedurerevealed the facility will determine their capacity and capability to care for each resident they admit and should not admit residents whose needs they cannot meet based on information they are provided with during the admission screening and referral process. Facility-initiated transfers or discharges may take place under any of the following circumstances: The discharge is necessary for the resident's welfare, the facility cannot meet the resident's needs, and/or the resident's clinical or behavioral status endangers the safety of individuals in the facility. However, further review of the policy revealed it did not address providing written notice to the resident's representative and Ombudsman when a resident was transferred or discharged . 1. Record review revealed the facility admitted Resident #1 on 04/10/18 with [DIAGNOSES REDACTED]. Review of e-mail notification of discharge revealed the Guardian was notified of discharge of Resident #1 on 09/21/18. However, further review revealed there was no documented evidence a written notice of discharge was provided to the resident's Guardian and Ombudsman that included the reason for discharge; effective date of discharge; location to which the resident was discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State until 09/24/18. This written notice was not signed by the resident nor guardian. Interview with the Social Worker on 10/03/18 at 2:10 PM revealed she notified the Guardian by phone on 09/20/18 of impending discharge but did not provide a written notice of discharge to include all information in policy until 09/24/18. Interview with Administrator on 10/03/18 at 4:45 PM revealed she was not here on 09/20/18 or 09/21/18 when Resident #1 was discharged . She stated she was waiting to see if the Psychiatric facility in Indiana could stabilize the resident before completing an official discharge notice. She revealed when she called the Psychiatric facility on 09/24/18, Monday, they told her they could not stabilize the resident yet and thus she made decision that she could not take the resident back as he/she was a danger to self and others and they could not meet the resident's needs. 2. Record review revealed the facility admitted Resident #3 on 12/28/17 with [DIAGNOSES REDACTED]. Review of Nursing Note revealed the resident was transferred to a Personal Care Home on 09/14/18 due to being above the facility's level of care. Review of Progress Note by Social Services dated 09/14/18 revealed notification received from Care Wise that Resident #3 was no longer meeting level of care and will have to be discharged to a Personal Care Home. Review of an email sent on 09/14/18 to the Ombudsman stating Resident #3 was discharged on [DATE] to a Personal Care Home due to being above level of care for the facility. However, there was no documented evidence of an official written notice of discharge was given to the Guardian/Ombudsman that included the reason for discharge; effective date of discharge; location to which the resident was discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests;and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, the name, address, (mailing and email) and telephone number of the Office of the State. Interview with the Director of Nursing (DON) on 10/03/18 at 8:45 AM and 10/04/18 at 12:30 PM revealed there was no official notice of discharge sent to the Guardian of Resident #1 and Resident #3. She stated Resident #3's Guardian was notified on 09/14/18 by phone and Resident #1's Guardian was notified by phone on 09/21/18. She further stated no official notification was provided because she did not think they had to do so. Interview with the Administrator on 10/04/18 at 4:58 PM revealed she was not aware the facility had to send discharge/transfer notices in written form in case of a voluntary discharge or transfer, and it was an omission on their part to not send notification in written form to Resident #1 and #3's Guardian and Ombudsman. She stated it was not in the facility policy to notify the Guardian and Ombudsman at the time of discharge and/or transfer.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Review of the facility Census and Condition, dated 12/04/17, revealed fifty-two (52) of fifty-three (53) residents received their meals from the kitchen. Observations on 12/04/17 and 12/06/17 revealed kitchen staff were observed with their hair not adequately restrained. The findings include: Review of the facility policy titled, Dietary Policy Personal Hygiene, not dated, revealed food employees shall wear hair restraints, such as hats, hair coverings, nets, beard restraints and clothing that are effective in keeping hair from contacting exposed food. Observation during the initial tour of the kitchen, on 12/04/17 at 11:30 AM, revealed four (4) dietary staff members; the Dietary Manager (DM,) Dietary Aide (DA) #1, DA #2 and DA #3, had hair hanging at the back of their necks, below their hair restraint. On 12/06/17 at 2:00 PM, the same staff had hair extending out of the hair restraints. In addition, the Dietician was observed to have hair from the temple area, extending to the jaw-line, out of the hair restraint. Interview with the Dietary Manager on 12/06/17 at 3:05 PM, revealed there was a policy in place and the dietary staff were expected to follow this. She stated she would ensure this was corrected. Interview with the Administrator on 12/06/17 at 3:30 PM, revealed the dietary staff had been trained on this and the Administrator stated this would be corrected.

Based on observation, interview, record review, review of the Activity Engagement Record, and facility policy review, it was determined the facility failed to develop a care plan with individualized interventions for each resident related to activities for three (3) of eight (8) sampled residents who were severely cognitively impaired (Resident #3, #29, and #36). Resident #3, #29 and 36 were assessed for what activities were were interested in however, the facility failed to develop a care plan that addressed the resident's activity interests for each resident. The residents were not receiving the activities according to the assessments. The findings include: Review of the Comprehensive Care Plan Policy dated 12/29/14 and revised 07/17/17 revealed it is the purpose of the comprehensive care plan to direct how each residents' daily care needs are provided by staff in accordance with the guidelines of the Resident Assessment Instrument (RAI) process and in keeping with the Medicare/Medicaid Services requirements. Residents should receive care and treatment based on an assessment of their needs, the severity of their [DIAGNOSES REDACTED]. The data obtained from the assessment is used to determine and prioritize the resident's Comprehensive Plan of Care. An individualized, person-centered comprehensive care plan, that includes measurable objectives and timetables to meet the resident's mental, physical, social, and spiritual needs is developed for each resident that identifies the highest level of functioning the resident may be expected to attain. Review of the facility Activity Care Plans Policy, dated 05/22/17, revealed the purpose of this policy is to develop individual plans of activities to promote the physical, mental and psychosocial well-being of the resident. An individual activity care plan is maintained for each resident. The Activities Department/Community Life Director will develop a plan of care in coordination with the resident's activity assessment. The activity plan contains a listing of activities that the resident enjoys or may enjoy, and has been approved by the resident/responsible party and the attending physician. Individual activity care plans are integrated into the resident's comprehensive care plan and recorded in the patient portal. Activity care plans are reviewed quarterly with the resident/responsible party and approved by the attending physician. 1. Record review revealed the facility admitted Resident #3 on 05/16/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/23/17, revealed the facility assessed Resident #3's cognition as severely impaired. In addition, the facility assessed the resident found it somewhat important to have books, newspapers, and magazines to read, found it very important to have animals around such as pets, found it very important for the resident to go outside to get fresh air when the weather is good, and found it very important to do his/her favorite activities. Review of the Comprehensive Care Plan related to activities, dated 05/19/17 revealed the resident would attend activities of choice and the goal would be for the resident to express/demonstrate satisfaction with level and type of activities provided. However, there were no individualized interventions to address the resident's assessed activity choices of going outside for fresh air; having books, newspapers and magazines to read; and being around animals such as pets. Review of the Activity Engagement Record for October, November and December 2017 and observations on 12/04/17 from 9:56 AM to 12:30 PM and 1:30 PM to 3:45 PM, 12/05/17 from 8:45 AM to 11 AM and 12:15 PM to 3:45 PM on 12/06/17 from 8:45 AM to 11:30 AM and 12:45 PM to 3:45 PM, and on 12/07/17 from 8:45 AM to 11:00 AM and 12:00 PM to 5:30 PM revealed the resident had one self initiated reading, one pet visit , two (2) one on one visits, one outside activity and sat in front of the television the common area. There was no evidence the resident was provided with outside activities, having books, newspapers and magazines to read; and being around animals such as pets consistently as assessed. 2. Record review revealed the facility admitted Resident #29 on 12/20/13 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 07/07/17 revealed the facility did not attempt to conduct a BIMS and the resident was not interviewable due to diagnoses. Review of the Annual MDS assessment, dated 07/07/17 revealed the facility did not attempt to conduct a BIMS and the resident was not interviewable due to diagnoses. Further review revealed the facility assessed it was very important to the resident to be around animals such as pets; somewhat important to listen to music, read books, newspapers, and magazines; to do things with groups of people and to go outside to get fresh air when the weather is good. In addition, it was very important to the resident to do favorite activities. However, review of the Comprehensive Care Plan related to activities dated 01/02/14 revealed the goal, was to continue interest in watching people in front of nurses station/lobby every day with verbal interaction; however, there were no individualized interventions to address the resident's assessed activity choices of animal visits; listening to music; reading books, newspapers and magazines; participating in groups; and outdoor activities. Review of the Activity Engagement Record for October, November and December 2017 and observations on 12/05/17 from 8:45 AM until 11:00 AM and 12:15 PM until 3:45 PM, on 12/06/17 from 8:45 AM until 11:30 AM and 12:45 PM until 3:45 PM, and on 12/07/17 from 8:45 AM until 11:00 AM and 12 :00 PM until 5:30 PM revealed Resident #29's activities consisted mainly of listening to music in his/her room. Resident #29 had one pet visit and group activity. There was no evidence the resident had any outdoor or reading activities provided and no evidence pet visits and group activities were provided consistently. 3. Record review revealed the facility admitted Resident #36 on 04/25/11 with [DIAGNOSES REDACTED]. Review of the the Quarterly MDS assessment, dated 10/18/17, revealed the facility assessed Resident #36's cognition as severely impaired with a BIMS score of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed it was very important for the resident to have books, newspapers, and magazines to read; music to listen to; to be around animals such as pets; to get fresh air outside when weather is good; and to do his/her favorite activities. Review of the Comprehensive Care Plan dated 01/01/12 revealed a goal to attend social events when offered and will continue to engage in self initiated activities daily like watching TV and conversing with staff. Further review revealed interventions for the resident to attend activities of choice including pet visits and to self initiate activities daily such as watching TV and conversing with staff. However, there was no individual interventions for the resident to go outside when weather is permissible, have books, newspapers, and magazines to read; and music to listen to. Review of the resident's Activity Engagement Record for October, November and December 2017, and observations on 12/04/17 from 9:56 AM until 12:30 PM and 1:30 PM until 3:45 PM, on 12/05/17 from 8:45 AM until 11:00 AM and from 12:15 PM until 3:45 PM, and on 12/07/17 from 8:45 AM until 11:00 AM and from 12:00 PM until 5:30 PM revealed the resident listened to music four (4) times, had one (1) pet visit, and had the television on. There was no evidence the resident was provided any reading activity or outside activities as assessed. Interview with Activities Director on 12/07/17 2:45 PM revealed she completed all assessments and all care plans for all residents for activities. Interview with Director of Nursing on 12/07/17 4:00 PM revealed person centered care plans were important to assure each resident's chosen activities were what the resident wanted and were individualized for each resident. Interview with the Administrator on 12/07/17 at 4:25 PM revealed she expects an individualized approach according to care plan. She stated the Activities Director is responsible for assessment of residents and the MDS Coordinator utilizes those assessments as needed.

Based on observation, interview, record review, review of Activity Engagement Record and facility policy review, it was determined the facility failed to ensure activities meet the needs of four (4) of eight (8) severely cognitively impaired residents (Resident #3, #9, #29 and #36). The facility failed to provide onging activities for Resident #3, #9, #29 and #36 as assessed. The findings include: Review of the facility Activity Care Plans Policy, dated 05/22/17, revealed the purpose of this policy is to develop individual plans of activities to promote the physical, mental and psychosocial well-being of the resident. An individual activity care plan is maintained for each resident. The Activities Department/Community Life Director will develop a plan of care in coordination with the resident's activity assessment. The activity plan contains a listing of activities that the resident enjoys or may enjoy, and has been approved by the resident/responsible party and the attending physician. Individual activity care plans are integrated into the resident's comprehensive care plan and recorded in the resident portal. Activity care plans are reviewed quarterly with the resident/responsible party and approved by the attending physician. Review of the Activity Program Policy, dated 05/24/17, revealed it's purpose is to ensure there is an ongoing program of activities designed to meet the needs of each resident. Review of the Activities Coordinator Job Description, not dated, revealed the purpose of the Activities Coordinator is to plan and implement a wide range of activities and services that enables residents to react and interact with their environment; enables residents in filling leisure time according to their individual interests and to find a new and satisfying social relationships; and to be able to be self-directing and spontaneous. Review of the facility Activity Engagement Record revealed the record allows documentation for X Attended with Contribution, R Refused, SI Self-initiated Activity, and 1 Activity 1:1. The document also lists various activities available for residents including arts and crafts, cards and games, current events, community outings, educational, exercise/ball toss/etc, family visits, happy hour, image enhancement, movies/DVD, music, music man/guests, nail art, outdoors/patio, parties/special event, pet visits, resident council, reading, reminiscing, rummaging, snack and chat, stack and sort, socializing with peers, spiritual/religious, special groups, telephone and trivia. 1. Record review revealed the facility admitted Resident #3 on 05/16/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/23/17, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the facility assessed Resident #3 found it somewhat important to have books, newspapers, and magazines to read, found it very important to have animals around such as pets, found it very important to go outside to get fresh air when the weather is good, and found it very important to do his/her favorite activities. Review of the Comprehensive Care Plan related to activities dated 05/19/17 revealed Resident #3 would attend activities but there were no individualized interventions to address what activities the resident found important. Review of the Activity Engagement Record for October, November and December 2017 revealed the resident had no reading activities or pet visits in October and November; and one self initiated reading and pet visit in December. Further review revealed there were no one on one visits with Activities in October and November; and two (2) one on one visits for December. In addition, the resident only went outside one (1) time on 10/05/17. Observations on 12/04/17 from from 9:56 AM to 12:30 PM and 1:30 PM to 3:45 PM noted resident in bed or sitting in commons area in front of TV, except at lunch. Observations on 12/05/17 from 8:45 AM to 11 AM and 12:15 PM to 3:45 PM revealed the resident was in bed except at lunch. Observation on 12/06/17 from 8:45 AM to 11:30 AM and 12:45 PM to 3:45 PM, revealed the resident was in bed or up at lunch. Observation on 12/07/17 from 8:45 AM to 11:00 AM and 12 PM to 5:30 PM revealed the resident was sitting in commons area in front of TV, and after lunch the resident was in bed. 2. Record review revealed the facility admitted Resident #9 on 09/12/14 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 08/30/17, revealed the facility assessed Resident #9's was unable to complete the interview and was not interviewable. Further review of the MDS assessment dated [DATE] revealed it was very important to the resident to listen to music, to do things with groups of people, to go outside to get fresh air and to do his/her favorite activities. Review of the Comprehensive Care Plan, dated 09/22/14, revealed interventions for Resident #9 to attend music events, spend time outdoors, and attend parties and church services Review of the October, November and December 2017 Activity Engagement Records revealed the resident listened to music nine (9) of thirty-one (31) days in October, ten (10) of thirty (30) days in November, and six (6) of seven (7) days in December. Further review revealed there were no group activities or outdoor activities provided. Observations on 12/04/17 from 9:56 AM until 12:30 PM and from 1:30 PM until 3:45 PM revealed the resident was in bed with no music playing in room. Observation on 12/05/17 from 8:45 AM until 11:00 AM and from 12:15 PM until 3:45 PM revealed the resident was lying in bed with no music playing. Observation on 12/07/17 from 8:45 AM to 11:00 AM and 12 PM to 5:30 PM revealed the resident was in geri-chair in his/her room with no music playing. 3. Record review revealed the facility admitted Resident #29 on 12/20/13 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 07/07/17 revealed the facility did not attempt to conduct a BIMS and the resident was not interviewable due to diagnoses. Further review revealed the facility assessed it was very important to the resident to be around animals such as pets; somewhat important to listen to music, read books, newspapers, and magazines; to do things with groups of people and to go outside to get fresh air when the weather is good. In addition, it was very important to the resident to do favorite activities. Review of the Comprehensive Care Plan related to activities, dated 01/02/14, revealed the care plan was not individualized to address Resident #29's interests to include animal visits; listening to music; reading books, newspapers and magazines; participating in groups; and outdoor activities. Review of the Activity Engagement Record for October, November and December 2017 revealed Resident #29 listened to music three (3) times in October, five (5) times in November and nine (9) times in December. Resident #29 had no pet visits in October and November and one visit in December; and one group activity in October, and none in November and December. Further review revealed there were no outdoor or reading activities in October, November and December. Observations on 12/05/17 from 8:45 AM until 11:00 AM and 12:15 PM until 3:45 PM. revealed the resident was either in his/her geri chair or bed. Observation on 12/06/17 from 8:45 AM until 11:30 AM and 12:45 PM until 3:45 PM. revealed the resident was in bed or geri chair except at lunch time. Observation on 12/07/17 from 8:45 AM until 11:00 AM and 12 :00 PM until 5:30 PM revealed the resident was in bed or up in geri chair for lunch. The resident was listening to music in his/her room with a CD player brought to her room. 4. Record review revealed the facility admitted Resident #36 on 04/25/11 with [DIAGNOSES REDACTED]. Review of the the Quarterly MDS assessment, dated 10/18/17, revealed the facility assessed Resident #36's cognition as severely impaired with a BIMS score of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed it was very important for the resident to have books, newspapers, and magazines to read; music to listen to; to be around animals such as pets; to get fresh air outside when weather is good; and to do his/her favorite activities. Review of the Comprehensive Care Plan dated 01/01/12 revealed interventions for the resident to attend activities of choice including pet visits, and self initiate activities daily such as watching TV and conversing with staff. However, the care plan did not address going outside as assessed by the facility. Review of the resident's Activity Engagement Record for October, November and December 2017, revealed the resident listened to music three (3) times in October, three times in November and one (1) time in December and and had a pet visit one (1) time in December. Further review revealed there were no reading activity, or outside activities for October, November or December. Observations on 12/04/17 from 9:56 AM until 12:30 PM and 1:30 PM until 3:45 PM, revealed the resident was in bed with covers pulled over his head. Observations on 12/05/17 from 8:45 AM until 11:00 AM and from 12:15 PM until 3:45 PM revealed the resident was in bed. Observations on 12/07/17 from 8:45 AM until 11:00 AM and from 12:00 PM until 5:30 PM revealed was in bed with TV on. Observation of a Group Activity in the commons area, on 12/04/17 at 9:45 AM, revealed the resident were making Christmas Ornaments. On 12/05/17 at 1:30 PM, the Activity Director was observed in the Commons Area with residents participating in a beading project. There were three (3) residents in the group. On 12/06/17 at 2:30 PM the Activity Director was observed in a small room with two (2) residents listening to music. On 12/07/17 at 10:30 AM, the Activity Director was in the Commons Room sitting at a table with two (2) residents around her discussing the Christmas tree that was going to be put up later. Interview with Certified Nurse Aide (CNA) #1, on 12/07/17 at 2:32 PM, revealed she helps bring residents to group activities but doesn't recall bringing Residents #3, #9, #29 and #36 to group activities. She stated she has brought them to watch TV in commons area. She stated she knows which residents go to groups but there are no specific times or dates that she brings them. She revealed if a resident appeared anxious or was wandering in the hall, she would ask if the resident wanted to go to the commons room for an activity or watch TV. Interview with Activities Director on 12/07/17 at 2:45 PM revealed she provides adequate activities for all residents. She stated she did complete all of the activity assessments. She revealed she did not have much help with activities but if she needed help moving residents to the commons area, the staff would help her. She provided a calendar of events for the month of December 2017 and stated if a resident wanted to come to a group event, she brought them to the area or she asked staff to help her. She revealed she has a room she brings residents to that need a quiet place to listen to music or watch a movie. She further stated she did bring Residents #3, #9, #29, and #36 to that room from time to time. Interview with Director of Nursing 12/07/17 at 4:00 PM revealed she will attempt to engage in group activities and will provide one on one if required. She stated the CNA's should check Kardex to see what needs to be done and find an activity that can be done with the resident at that time. She revealed the CNA's and other staff are expected to help with activities. She stated there were also behavior boxes available if residents need more attention and there were different tasks for low BIMS residents. She revealed there are also behavior boxes that have restless activities in them like sorting socks or folding wash clothes. Interview with Administrator on 12/07/17 at 4:25 PM revealed she expects an individualized approach for activities according to the resident's care plan and staff are to assist as needed. She stated the Activity Director tries to accommodate the residents' individualized needs and does one on one if needed.

Based on interview and record review and review of the facility's policy and procedure, it was determined the facility's Quality Assessment and Assurance Program failed to effectively monitor a new system to ensure residents that required mechanically altered food received the appropriate food form per their therapeutic mechanically altered diet and failed to ensure assistance/supervision with feeding was provided for two residents (#2 and #3) in the selected sample of seven to correct identified quality deficiencies related to choking. On 01/22/12, the facility staff served a bologna sandwich to Resident #3 which was not mechanically altered providing no staff feeding/supervision. The facility staff witnessed the resident choking, unable to breathe, having no air movement to the lungs and ashen in color. The facility staff had to perform the [MEDICATION NAME] Maneuver. The facility down-graded the resident's diet to pureed meat; however, on 03/15/12, the facility staff was observed serving Resident #3 meat that was not pureed and did not provide feeding/supervision. The facility was knowledgeable of Resident #2's physician order [REDACTED].#2 meat that was not in the appropriate food form per the diet order. The facility staff witnessed the resident choking, face turning red and had to perform the [MEDICATION NAME] Maneuver. Inservicing and monitoring was put into place, however, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee could not provide evidence the system was monitored to ensure residents received the appropriate food form per their diet order and supervision to prevent choking. Additionally, the facility's Quality Assessment and Assurance Program failed to identify quality of care issues for one resident (#1) in the selected sample of seven related to aggressive behaviors towards other residents. The facility had assessed and care planned Resident #1 for aggressive behaviors, however, had not identified it's failure to ensure four residents (#4, #5, #6 and #7), in the selected sample of seven residents, were free from physical and mental abuse from Resident #1. On 01/20/12, Resident #1 made threats of harm toward Resident #7. On 02/08/12, the facility received an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible. Resident #7 was fearful of Resident #1 and told a Certified Nurse Aide (CNA) and Registered Nurse (RN) that he/she wanted to be moved to another room, away from Resident #1, who was threatening him/her. On 02/11/12, Resident #1 physically attacked a staff member throwing him/her on the bed and kicking his/her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #4, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 had substantial bruising to his/her bilateral hands and CNA #9 reported that Resident #4 was "really afraid" after the altercation and that he/she was screaming, crying, trembling, and pacing the floor all night after the altercation. Further review of Resident #4's nurses' notes, on 02/19/12 at 4:55 PM, revealed Resident #4 stated "I need a gun." RN #1 determined Resident #5 had no physical injuries; however, CNA #9 reported that Resident #5, who was wheelchair bound, refused to come out of the safety of his/her room for the remainder of the night after the altercation. The facility failed to identify Resident #1's aggressive and escalating behaviors toward other residents as a trend requiring reassessment and new interventions and supervision in an effort to protect residents residing in the facility. These failures to identify quality care concerns inorder to implement corrective measures to ensure quality care is provided caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 01/22/12 and 02/08/12 and is ongoing. Prior to exit, the facility did not submit an Allegation of Compliance to remove the Immediate Jeopardy. (Refer to F223, F225, F226, F250, F323, and F365) Findings Include: 1. (Refer to F323, F365) A review of Resident #3's record revealed the facility assessed and care planned that staff would totally feed Resident #3 and provide the mechanically altered diet as physician ordered. On 01/22/12, the facility staff served the resident a bologna sandwich which was not mechanically altered per the facility's policy and did not feed the resident. Facility staff found the resident choking and administered of the [MEDICATION NAME] Maneuver. Dietary staff was inserviced, on 01/22/12, related to the different types of diet textures. The resident's care plan was revised to "monitor closely for choking." However the facility's investigation did not identify facility staff did not feed Resident #3 per the care plan. A review of Resident #2's record revealed the physician had signed the Occupational Therapy document detailing the resident required supervision and assistance with feeding on 09/27/12. On 02/26/12 per the facility's investigation report, facility staff observed the resident choking and administered the [MEDICATION NAME] Maneuver. The investigation detailed the resident was not served meat that had been mechanically altered. Thus not complying with the physician's orders [REDACTED]. While the facility in-serviced all staff on the types of therapeutic diet consistencies and the process for ensuring accurate food consistencies were served to the residents through monitoring by the cook, the dietary assistant, the Dietary Manager and the Certified Nurse Aide (CNA) and nurses were to check the tray again when delivered to the resident. The facility could provide no evidence that they monitored the effectiveness of their new system to ensure there were no further quality concerns. Furthermore, an observation of the lunch meal, on 03/15/12, revealed the facility staff served Resident #3 meat that was not pureed as per the diet card and no nursing staff fed the resident. Interviews with the DM and the assigned CNA revealed the food was not the appropriate consistency and no staff was feeding the resident. Interview with the Registered Dietitian, on 03/21/12 at 3:40 PM, revealed the facility cites the Academy of Nutritional Dietetics as their reference for standards of practice and policy and procedure. A review of Level 2 Nutrition Therapy for Dysphasia; Mechanically Altered Foods, undated, included "The purpose of mechanically altering foods is to provide foods that can be successfully and safely swallowed. This diet consists of foods that are mechanically altered by blending, chopping, grinding or mashing so that they are easy to chew and swallow. Foods in large chunks or foods that are too hard to be chewed thoroughly should be avoided." The Foods not Recommended section included "hotdogs" and "sandwiches." An interview with the Administrator (a certified nutritionist), and the Director of Nursing (DON), on 03/16/12 at 4:00 PM, revealed mechanically altered diet meant the food was to be "put through a machine," no raw vegetables, very soft bread, crackers and toast was acceptable, and that "when put in the mouth would become soft." While the facility initiated corrective action after the 01/22/12 incident, as well as the incident on 02/26/12, the facility could not provide evidence that they effectively monitored the new system to ensure resident's requiring mechanically altered meals received the appropriate food form per their diet order to prevent potential choking episodes. 2. The facility failed to to identify, assess and evaluate that Resident #1 had aggressive and dangerous behaviors which affected and/or harmed four residents and placed other residents at risk for harm. A review of an investigation worksheet, dated 02/14/12, revealed Resident #1 had a verbal confrontation with Resident #6 which necessitated a room change for Resident #6. While the facility initiated a room change for Resident #6, a review of the care plan after this incident, revealed the facility made no changes to address the resident's verbally aggressive behaviors, nor made revisions to the interventions in an effort to manage the behaviors and/or ensure protection of other residents in the facility. There was no evidence the facility identified Resident #1's behaviors as abusive. The facility failed to provide appropriate investigation and interventions for Resident #7 who was struck in the head by Resident #1. A room change was made for Resident #7 without evidence the facility had investigated related to the allegation of physical abuse or to the reasons for the resident's room change request. Therefore, there was no evidence the facility addressed the resident's physical aggression or provided protection to other residents of the facility to prevent further potential abuse. A review of the nurse's notes and the investigation worksheet, dated 02/19/12, revealed facility staff heard a commotion and found that Resident #1 had "pinned" Resident #4 with his/her face to the hallway wall, and Resident #1 had restrained both of Resident #4's wrists with his/her hands. The facility staff separated Resident #1 and Resident #4, at which time Resident #1 immediately turned and grabbed Resident #5's clothing. Resident #5 was wheelchair bound, having had a bilateral hip level amputation. Resident #1 attempted to pull Resident #5 from his/her wheelchair. The facility staff escorted Resident #1 to the facility's UK Den at which time the facility notified the police. An interview with the police, on 03/21/12 at 11:00 PM, revealed the incident was considered a fourth (4th) degree assault. A review of the facility's policy/ procedure, "Resident Abuse, Neglect and Exploitation," dated 02/07/12, revealed the facility's goal was "to have a process in place to protect the health and welfare of each resident and to assure each resident was free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin". Prevention measures would include providing information and encouragement for reporting incidents, use of the Continuous Quality Improvement Process to identify and correct situations at high risk for abuse occurrence, areas of the building and grounds that provided increased risk for abuse, staff training and documentation tools used for abuse identification and reporting, identification of residents whose personal histories and/or [DIAGNOSES REDACTED]. The section titled Identification distinguishes abuse by a staff member from resident to resident abuse. The Abuse by a staff member section identified steps to follow as reporting immediately to the employee's immediate supervisor with immediate suspension until the investigation resolved the issue and reporting of the incident to the appropriate entities. In the occasion of resident to resident abuse, the residents involved in allegations of resident-to-resident abuse should be separated from each other to first assure resident's safety and protection with notifications made to the appropriate entities. An evaluation of the alleged perpetrator would be completed to determine a potential cause related to a medical need. The alleged victim would be evaluated and treated as needed. Reporting the alleged abuse would include documentation of injuries, investigation documentation, and reports to the appropriate authoritative entities. Administrator interview, on 03/17/12 and on 3/22/12 at 11:55 AM , revealed that while she was not familiar with the resident's [DIAGNOSES REDACTED]. The Administrator reported behavior management training was provided to staff with a focus on the Crisis, Prevention, and Intervention (CPI) program with additional workshops on general behaviors to include dementia. The Administrator was unable to provide evidence that the facility had trained the staff on behavior management related to Resident #1's [DIAGNOSES REDACTED]. She stated she believed it was the staff's responsibility to identify a need for specific behavior management training and ask the administrative nurse to set it up with the psychiatrist. She revealed that the staff doesn't take credit for use of CPI interventions because it wasn't successful for more than a short time. Interview with the Administratorrevealed Resident #1's aggressive behaviors toward other residents had not been addressed through the Quality Assessment and Assurance Program.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to revision of care plans of residents who were identified at risk for resident to resident abuse and on specialty diets. However, non-compliance continued to exist at a S/S of a "E" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to the revision of care plans of residents who were identified at risk for resident to resident abuse and on specialty diets. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the care plans for residents #1, #4, #5, #6, and #7 were revised on 03/29/12 by the Social Services Director and the Minimum Data Set (MDS) Coordinator to include interventions and approaches specific to each resident. In relation to the new system of daily monitoring incident reports, the resident care plans were reviewed and updated accordingly by the charge nurse of other appropriate discipline. In addition, care plan changes were monitored daily by the DON or administrative nurse in charge. Care plans were also reviewed and revised in regard to information gathered from the Behavior Observation Program (BOP) sheets on a daily basis. All resident dietary care plans were reviewed and revised by the Registered Dietitian (RD) or Certified Nutritionist (CN) on 03/29/12. A comparison between the physician's orders [REDACTED]. A daily review with updates as needed was performed by the Registered Dietitian and/or the Certified Nutritionist. A system has been established for charge nurses to report, on a daily basis, any dietary care plan changes not made by the RD or CN to the DON who would then report the changes to the RD or CN for review. A daily report was made to the Corporate Compliance Nurse detailing dietary care plans and diet orders. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview and record review, it was determined the facility failed to revise the care plan for four residents (#1, #2, #5 and #6), in the selected sample of seven residents. The facility failed to revise the care plan for Resident #1 after having multiple incidents of escalating aggressive behaviors towards other residents of the facility and staff. The facility was aware of incidents occuring on 01/20/12, 02/08/12, 02/11/12, 02/14/12, and on 02/19/12 however, there was no evidence that the facility revised the behavior care plan to implement effective interventions to address the Resident's behaviors related to his/her [DIAGNOSES REDACTED].#4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #5, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. While the facility initiated one to one supervision after the incident of 02/19/12, they failed to ensure it was continuous until the facility transfered Resident #1 to the psychiatric hospital. The facility readmitted Resident #1 on 03/05/12; however, made no revisions to the care plan to address the resident's behaviors and violent history. Residents #5 and #6 had varied behaviors which included verbal and physical aggression, socially inappropriate behaviors, verbal and physical threats toward others, yelling out, and destroying property. The facility utilized Behavior Observation sheet, Side Effect Monitoring and [MEDICAL CONDITION] (BOP) reports to monitor the residents' behaviors and response to the implemented interventions. A review of resident records and interviews revealed interventions were implemented with little to no success and care plans were not revised. Resident #2 required a therapeutic diet and had been assessed to require staff assistance for feeding. The resident's care plan did not reflect the Occupational Therapy Evaluation and Plan of Treatment signed by the physician. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 03/21/12 and determined to exist on 01/22/12 and 02/08/12 and is ongoing. Prior to exit, the facility did not submit an Allegation of Compliance to remove Immediate Jeopardy. (Refer to F223, F250, and F323) Findings include: 1. A record review revealed the facility admitted Resident #1 on 04/07/06 with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, dated 11/23/11, revealed a plan for agitated behavior such as banging his/her walker on the floor, throwing objects, hitting staff and threatening others secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. A review of the care plan interventions revealed descriptions to include "offer diversional activities of enjoyment," "monitor closely for signs of increased frustration and/ or anxiety," and "attempt to identify any stimuli that may trigger episodes." The care plan was initiated on 11/23/11 with annotation to continue with all approaches on 02/20/12. A "Short Term Temporary Care Plan," dated 02/19/12 to end 03/19/12, had the focus problem of "altercation with another person." A review of the BOP report and the Behavior Management Log, dated February 2012, revealed behaviors on seventeen (17) days, and in March 2012, there were nine (9) days with documented behaviors and little to no success as the response to staff interventions of verbal cues and redirection. 2. A record review revealed the facility admitted Resident #5 on 05/06/11 with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, initiated 05/15/11, revealed a plan for socially inappropriate/ disruptive behavior, such as throwing food trays and destroying property. The care plan was reviewed and updated, on 08/05/11, 11/03/11, and 01/26/12, without changes made. A review of the care plan interventions revealed descriptions to include "attempt to discover and correct cause," "reward desirable behaviors," and "monitor/record mood/behavior every shift on the BOP sheets." The Minimum Data Set (MDS), dated [DATE], identified Resident #5 as having no behaviors exhibited and rejection of care occurred one (1) to three (3) days. A review of the Behavior Management Log revealed twenty-three (23) days in February 2012 with behaviors, and six (6) days in March 2012, with little to no success as the response to the interventions of verbal cues and redirection. 3. A record review revealed the facility admitted Resident #6 on 02/09/12 with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, initiated 02/15/12, revealed a plan for Potential to demonstrate physical behaviors. A review of the care plan interventions revealed descriptions to include "monitor and document observed behavior and attempted interventions," "when becomes agitated, intervene before escalates, guide calmly in conversation, if response is aggressive, staff to walk calmly away." The MDS, dated [DATE], identified Resident #6 as having physical and verbal symptoms directed toward others occurred one (1) to three (3) days and behavioral symptoms not directed toward others four (4) to six (6) days. A review of the Behavioral Management Log revealed eleven (11) days in February 2012 with behaviors, and seven (7) days in March 2012 with behaviors and little to no success as the response to the interventions of verbal cues and redirection. An interview with the Director of Nursing (DON), on 03/21/12 at 4:15 PM, revealed the assessment of care plan effectiveness was the responsibility of the person who wrote the care plan, and the behavior care plans were written and adjusted by the Social Services Director. (Refer to F-250). Any adjustments to the care plan should be reported to the administrative nurses. The DON revealed the facility had not determined if the staff understood the function of the care plans. An interview with the Social Services Director, on 03/22/12 at 12:05 PM, revealed the transfer of information related to specifics for care plan interventions, such as how to intervene before behaviors escalated, was accomplished with a verbal transfer of instruction from one CNA to another, and through communication with the resident. The Social Services Director considered it "common sense" for nursing to assess and attempt to modify the underlying causes for agitation. The Social Services Director revealed there was no difference between "monitor" and "monitor closely" when stated on the care plan interventions and the responsibility for identification of behavior escalation beyond the shift to shift verbal exchange belonged to the nurses as they see the behavior slowly building. In response to the care plan intervention "reduce distractions and negative environmental stimuli," the Social Services Director revealed the facility had not identified triggers or stimuli connected to the explosive behaviors for Resident #1. 4. A record review revealed the facility admitted Resident #2 on 04/10/08 with [DIAGNOSES REDACTED]. Review of a Occupational Therapy Evaluation and Plan of Treatment, dated 09/13/11 and signed by the physician on 09/27/11, revealed the resident demonstrated increased spillage, and requires staff assistance for feeding. A review of Resident #2's care plan, titled Nutrition and dated revised 09/27/11, 10/12/11 and 12/13/11, revealed "assist with tray set up as needed. The Nursing Assistant Care Plan, dated 03/2012, revealed "feeds self " and "assist with feeding as needed". The care plan was not revised to implement the Occupational Therapy Evaluation and Plan of Treatment, signed by the physician on 09/27/11, for staff assistance for feeding. Observations of the noon meals on 03/15/12 and on 03/16/12 revealed Resident #3 in his/her room eating without any staff assistance. Two CNAs were located accross the room each feeding other residents and Resident #2 was feeding him/herself.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure adequate supervision was provided to five residents (#2, #3, #4, #5 and #7), in the selected sample of seven residents. The facility failed to follow their "Resident Abuse, Neglect, and Exploitation" Policy and the Close Supervision/One to One policy. The facility failed to follow the abuse policy/procedure. The facility failed to identify the Resident #1's personal history, diagnoses, and the facility's assessment of Resident #1, as factors that could render him/her to be a risk for abuse toward other residents requiring supervision to prevent abuse and to protect other residents from potential abuse. Staff interviews revealed they knew they should not turn their back to Resident #1 due to his/her history of violence toward other residents and staff. Resident #1's attending psychiatrist stated Resident #1 demonstrated classical Intermittent Explosive Disorder and described these behaviors as unpredictable for the intensity of the violence and that the actions are not planned, but willful, as the anger is demonstrated in "all-out" aggression. On 01/20/12, Resident #1 made threats of harm toward Resident #7. On 02/08/12, the facility received an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible. On 02/11/12, Resident #1 physically attacked a staff member throwing him/her on the bed and kicking his/her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #5, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. While the facility initiated one to one supervision after the incident of 02/19/12, they failed to ensure it was continuous until the facility transferred Resident #1 to the psychiatric hospital. The facility readmitted Resident #1 on 03/05/12; however, failed to continue supervision to protect the residents of the facility. Observation of Resident #1 on 03/16/12 revealed this resident was allowed access to all residents without staff supervision despite his/her escalating behaviors resulting in physical abuse. The facility could provide no evidence detailing that they identified Resident #1's behaviors as a risk for potential abuse, initiated an investigation or implemented interventions of supervision of Resident #1 to protect other residents from further potential abuse. There was no evidence the facility followed the "Resident Abuse, Neglect, and Exploitation" policy/procedure, Prevention Section, to ensure the residents' safety and protection through identification and correction of situations in which abuse is more likely to occur, through supervision of staff members who were trained to identify and report inappropriate behaviors, and through monitoring and reassessment of resident needs and behaviors which might lead to conflict. The facility failed to follow standards of practice related to therapeutic diets and providing supervision to residents assessed as requiring feeding assistance. The facility was knowledgeable regarding Resident #2 and #3's need for therapeutic mechanically altered diet, per physician's orders [REDACTED]. On 01/22/12, the facility failed to provide total feeding assistance and supervision to Resident #3 after serving him/her a bologna sandwich which was not mechanically altered. The facility staff witnessed the resident choking, unable to breathe, having no air movement to the lungs and ashen in color. The facility staff had to perform the Heimlich Maneuver. The facility down-graded the resident's diet to pureed meat; however, on 03/15/12, the facility staff was observed serving Resident #3 meat that was not pureed and failed to provide total feeding assistance supervision. Additionally, on 02/26/12, the facility failed to provide assistance with feeding and supervision per the Occupational Therapy evaluation signed by the physician. The facility served Resident #2 meat that was not mechanically altered and was not assisting the resident with feeding during the meal. The facility staff witnessed the resident choking, face turning red and had to perform the Heimlich Maneuver. While the facility had identified the issue of Resident #3 receiving food during meal service that was not in the food form per the physician's orders [REDACTED].#2, observation of the meal service on 03/15/12 revealed the interventions the facility had implemented were not effective as Resident #3 continued to receive a diet that was not in the appropriate food form as required and was not being provided assistance and supervision with feeding for the resident's safety to prevent choking. These facility failures to ensure adequate supervision of residents with aggressive behaviors to prevent harm and of residents requiring supervision/assistance during meals due to swallowing and choking risk caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 01/22/12 and is ongoing. Prior to exit, the facility did not submit an Allegation of Compliance for the removal of Immediate Jeopardy. Findings include: A review of the facility's policy/procedure, "Resident Abuse, Neglect, and Exploitation", dated 02/07/12, revealed it is the goal of the facility to have a process in place to protect the health and welfare of each resident; to assure that each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin. If a resident to resident altercation occurs, the resident's safety and protection will first be assured. The residents shall be separated from each other and the families and physicians shall be notified. An investigation will be performed to determine if abuse has occurred. If it is determined that abuse has occurred, an evaluation of the abusing client shall be completed to determine if there is a problem that would require medical intervention. The incident will be viewed as a reportable incident with proper protocol followed and the appropriate agencies will be notified. A record review of the Concord Health Systems Close Observation or One-on-One Supervision policy, dated 03/17/10, revealed the one to one supervision nursing intervention would be initiated as needed to ensure safety of residents and/or prevent injury. Stated reasons to initiate one-to-one supervision include resident safety and behaviors described as agitated, unpredictable or aggressive. The facility staff designated as responsible for assessing the situation and initiating the one-to-one supervision would be the charge nurse. A record review revealed the facility admitted Resident #1 on 04/07/06 with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as cognitively intact and participated in the assessment and goal setting process for care. The facility initiated a Behavior Care Plan, dated 11/23/11, which revealed staff was to "offer diversional activities" and "monitor closely." An interview with the psychiatrist, on 03/21/12 at 12:08 PM, revealed he was familiar with Resident #1 since 2008 and sees the resident on a regular basis in the facility. He stated Resident #1 demonstrates classical Intermittent Explosive Disorder, which is a disorder known to be genetic. The psychiatrist further reported Intermittent Explosive Disorder as a frequently missed [DIAGNOSES REDACTED]. The psychiatrist described these behaviors as unpredictable for the intensity of the violence and that the actions are not planned, but willful, as the anger is demonstrated in "all-out" aggression. The psychiatrist further described Resident #1 as being "pretty sick" with the combined [DIAGNOSES REDACTED]. Resident #1 was described as being able, at times, to communicate and demonstrate cognitive orientation through knowledge of the United States President, the Vice President, and the Governor of Kentucky, and other times, he/she was out of control and unable to communicate. The resident did not make plans or plot to hurt others, but acted immediately on his/her thoughts when angry, and without regard for consequences. The psychiatrist described the explosive behavior as "all out aggression when ticked off." He stated Resident #1 meant to hurt others when he/she exploded and acted on his/her anger. A review of the nurse's notes, dated 01/20/12 at 3:00 AM, revealed facility staff heard Resident #1 cursing his/her roommate (Resident #7), while he/she slept, and Resident #1 continued to verbally threaten the roommate even after attempts of diversional activities by the staff. Additionally, a nurse's note, dated 01/20/12 at 4:00 AM, further revealed Resident #7 was out of the room and Resident #1 continued to curse and threaten Resident #7. A review of the Behavior Observation, Side Effect Monitoring and Delirium (BOP) report, dated 01/20/12, revealed the facility staff identified Resident #1's behaviors on the evening shift as verbally abusive behaviors that were not easily altered. An interview with CNA #9, on 03/16/12 at 12:30 PM, revealed Resident #1 was often found standing over Resident #7 while he/she slept. On 01/20/12, care plan interventions to include "offer diversional activities" and "monitor closely" continued with no new interventions added to address the ineffectiveness of the same care plan interventions being utilized, both before and after the resident's aggressive behavior. There was no documented evidence the facility initiated an investigation of the incident related to Resident #1 threatening Resident #7, as identified on both the BOP report and the Behavior Management Log. Furthermore, there was no implementation of new care plan interventions or supervision to ensure the protection of Resident #7 or other residents in the facility from Resident #1's aggressive, threatening behaviors. A review of the February 2012 Behavior Observation, Side Effect Monitoring and Delirium (BOP) report and the February Behavior Management Log revealed the resident showed persistent aggressive behavior symptoms including verbal abuse, cursing, yelling, threatening and physical attacks, without the facility staff determining interventions were successful. On 02/02/12, Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. On 02/04/12, Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate, disruptive behaviors, and sexual comments. On 02/05/12, Resident #1 exhibited behavior symptoms of cursing, yelling, and threatening. On 02/06/12 and 02/08/12 Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. A review of the facility's documentation revealed the interventions were unsuccessful. There was no evidence the facility reassessed the resident for new interventions to manage his/her behaviors or provide additional supervision to protect residents of the facility from potential abuse. An interview with Resident #7, on 03/20/12 at 10:45 AM, revealed Resident #1 had struck him/her on the head with a Bible sometime before his/her room transfer on 02/08/12. Resident #7 stated he/she requested a room transfer related to the threatening behaviors exhibited toward him/her by Resident #1. Interview with a Non-Facility Provider, on 03/20/12 at 12:05 PM, revealed that Resident #7 had informed her on two occasions of being "tired of that (resident)". Non-Facility Provider stated she reported to the facility that Resident #1 and Resident #7 had "heated words" and an inability to get along with each other. The Non-Facility Provider further revealed that Resident #7 told her that Resident #1 had struck Resident #7 on the head with a Bible. The Non-Facility Provider revealed she made a verbal report of physical abuse to Facility Staff #1. An interview with RN #1, on 03/16/12 at 2:25 PM, revealed that Resident #7 expressed a desire to change rooms and he/she did not like his/her roommate. An interview with CNA #9, on 03/16/12 at 12:30 PM, revealed Resident #1 was often found standing over Resident #7 while he/she slept during the time they were roommates. An interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed Resident #7 had requested a room change and was moved on 02/08/12. An interview with Facility Staff #1, on 03/20/12 at 12:15 PM, revealed the conversation with the Non-Facility Provider reported Resident #7 was unhappy with his/her roommate and desired a room change. The information was presented at the morning meeting. While the facility discussed and agreed to complete the room change for Resident #7, there was no evidence that the facility investigated the allegation of abuse made by the Non-Facility Provider. There was no evidence of a thorough review of Resident #1's care plan, dated 11/23/11, nor that the facility revised Resident #1's care plan related to increased supervision to protect other residents of the facility from further potential abuse by Resident #1. The care plan detailed the same care plan interventions that staff would "offer diversional activities" and "monitor closely." The Social Services Director was unaware that Resident #7 was struck on the head by Resident #1 prior to the room change on 02/08/12. There was no evidence the facility provided an investigation into the reason for the room change request made by the Non-Facility Provider on the behalf of Resident #7. Additional interview with the Administrator, on 03/17/12 at 9:30 AM, revealed Resident #1 was an "intimidator" and overall, was difficult to manage. Other residents were easily intimated by Resident #1 and the process of moving out his/her roommates reinforced his/her intimidating behaviors. CNA #4, on 03/19/12 at 3:30 PM, revealed Resident #1 exhibited behaviors everyday of cursing and ranting continuously, and "you would eventually get use to these behaviors after awhile, and it would no longer bother you anymore." Further review of the February 2012 Behavior Observation, Side Effect Monitoring and Delirium (BOP) report and the February Behavior Management Log revealed the resident showed persistent aggressive behavior symptoms including verbal abuse, cursing, yelling, threatening and physical attacks, without the facility staff determining interventions were successful. On 02/09/12, and 02/10/12 revealed Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. On 02/11/12, Resident #1 exhibited socially inappropriate and disruptive behaviors and verbal abuse. There was no evidence the facility modified the care plan to detail a change related to interventions that staff specified were not effective for Resident #1's behavior management or for supervision to protect other residents. A review of the nurse's notes, dated 02/11/12 at 4:30 AM, revealed Resident #1 became upset with staff during Activities of Daily Living (ADL) care and physically assaulted two staff. An interview with CNA #5, on 03/20/12 at 5:19 PM, and CNA #6, on 03/20/12 at 2:05 PM, revealed, on 02/11/12, while assisting Resident #1 for bed, the resident grabbed CNA #5 with his/her legs. Resident #1 "flipped" CNA #5 onto the bed and proceeded to forcefully kick CNA #5's head into the foot board of the bed. Resident #1 proceeded to throw a walker into the wall next to the CNA #6. An interview with LPN #4, on 03/20/12 at 3:20 PM, revealed Resident #1 was diverted by LPN #4's one-on-one attention after this incident, on 02/11/12. It took approximately 20 minutes before calmness was achieved. The facility could provide no documented evidence of this incident; however, interview revealed the information was passed on in shift report. A review of the care plan, after this incident, revealed the facility made no changes to address the resident's physically aggressive behaviors nor revisions to the care plan in an effort to manage the behaviors, and/or ensure protection of other residents in the facility. Furthermore, there was no evidence the facility attempted to investigate the incident or identify Resident #1 was at risk for abusing others. Attempts made by CNA #5 and CNA #6 to redirect Resident #1 were unsuccessful and the staff left the room to report the incident to the Charge Nurse. This incident was not detailed on the February 2012 BOP report or Behavior Management Log to indicate physically abusive behavioral symptoms, nor was there an investigation to determine the root cause of the resident's behaviors. There was no documented assessment or care plan revision provided by Social Services related to this incident. Interview with Licensed Practical Nurse (LPN) #4, on 03/20/12 at 3:20 PM, revealed although staff brought Resident #1 to the activities room outside the nurses station, there was no one to one supervision provided after she completed the diversion to the calm the resident. There was no evidence the facility assessed Resident #1 following this incident to determine the need to initiate increased supervision per their Close Observation/One to One supervision policy. Further review of the February 2012 BOP reports and Behavior Management Logs revealed on 02/12/12, Resident #1 exhibited verbal abuse with behavioral symptoms. On 02/13/12, Resident #1 exhibited socially inappropriate and disruptive behaviors and verbal abuse. On 02/14/12, Resident #1 exhibited socially inappropriate and disruptive behaviors. A review of the nurse's notes, dated 02/14/12 at 12:30 PM, revealed Resident #1 became verbally aggressive toward Resident #6, who was his/her roommate, and Resident #1 was placed on one to one supervision. The Close Observation or 1:1 Supervision document, dated 02/14/12, indicated Resident #1 was on one to one supervision from 12:30 PM until 11:30 PM. A review of the Investigation Worksheet, dated 02/12/12 at 12:30 PM, revealed Resident #1 was being verbally confrontational with Resident #7. Resident #1 was placed on 1:1 supervision and the room change for Resident #6 was completed on 02/14/12 at 2:00 PM. The BOP report revealed socially inappropriate/disruptive symptoms and the Behavior Management Log revealed Resident #1 was arguing and fighting with his/her roommate. The facility's documentation revealed there was no success with the facility's interventions of one one supervision. An interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed the room change for Resident #6 was the result of a verbal argument between Resident #6 and Resident #1 on 02/14/12. The facility Interdisciplinary Team and the Power of Attorney for Resident #6 decided the room change was necessary. A review of the Social Services notes, dated 02/10/12 with no time indicated, revealed Resident #6 was moved into the room with Resident #1 on 02/10/12. Social Services notes entry, dated 02/14/12, reports Resident #6 was moved out of the room with Resident #1 after four days related to verbal confrontations with one another. Social Services Director documented "no concerns noted." Although there was one to one supervision for eleven (11) hours, there was no other interventions except for a room change. There was no evidence the facility conducted an assessment, or revised the care plan to include increased supervision for Resident #1 to ensure behavior management or to protect other resident's of the facility. Further review of the February 2012 BOP report and Behavior Management Log revealed on 02/16/12, 02/17/12, 02/18/12 Resident #1 exhibited verbal abuse with behavioral symptoms. On 02/19/12, Resident #1 exhibited socially inappropriate and disruptive behaviors and verbal abuse. However, the documents revealed that none of the facility's interventions were effective related to the resident's behaviors. There was no evidence that the facility had changed the care plan to address the ineffective interventions related to the residents persistent behaviors. A review of the nurse's notes, dated 02/19/12 at 5:00 PM, the investigation worksheet, dated 02/19/12 at 9:35 PM, and interviews with CNA #9, on 03/16/12 at 12:30 PM, revealed CNA #9 heard yelling and went into the hall and witnessed Resident #1 pushing Resident #4's face up against the wall and restraining his/her hands against the wall. Resident #1 was removed by an employee and Resident #1 grabbed Resident #5 by the clothes and was going to pull him/her out of the wheelchair. It took two (2) staff members to escort Resident #1 away from the scene of the altercation and into the UK Den for de-escalation and one to one supervision. RN #1 assessed Resident #4 and Resident #5 for physical injuries. Resident #4 had substantial bruising to his/her bilateral hands and CNA #9 reported that Resident #4 was "really afraid" after the altercation and that he/she was screaming, crying, trembling, and pacing the floor all night after the altercation. Further review of the Resident #4's nurses' notes, on 02/19/12 at 4:55 PM, revealed Resident #4 stated "I need a gun." RN #1 determined Resident #5 had no physical injuries; however, CNA #9 reported that Resident #5, who was wheelchair bound, refused to come out of the safety of his/her room for the remainder of the night after the altercation. Further review of Resident #1's nurses' notes revealed that RN #1 notified the DON and Administrator, who contacted the local police for assistance. The police officer who responded reported that Resident #1 committed fourth (4th) degree assault. Upon visualization of the police officer, Resident #1 began to scream, complaining of chest pain. RN #1 notified the admitting hospital emergency room staff to give a report on Resident #1's complaints of chest pain and reported her fears that the resident would hurt someone. The facility initiated the "Short Term Temporary Care Plan," on 02/19/12, which detailed the altercation with another resident and specified staff would remove residents from the area/situation, notify the Charge Nurse immediately, assess residents for any harm, provide safe environment, notify the physician and responsible party of the incident, and the need for one to one supervision. The facility readmitted Resident #1 from the hospital emergency room , on 02/20/12 at 2:25 AM, and initiated one to one supervision. A review of the Close Observation or 1:1 Observation sheet documents revealed one to one supervision was defined as the resident being within reach/sight of a staff person at all times. Review of the document initiated on 02/20/12 for Resident #1 revealed the facility began one to one supervision at 2:30 AM and continued through 6:00 AM. However from 6:15 AM until 7:00 AM, there was no documented evidence the facility provided one to one supervision to ensure the safety of other residents of the facility or to ensure management of Resident #1's behaviors per their Short Term Temporary Care Plan. Further review of the February 2012 BOP report and Behavior Management Log revealed on 02/20/12 and 02/21/12, Resident #1 exhibited verbal abuse with behavioral symptoms. However, the documents revealed that none of the facility's interventions were effective related to the resident's behaviors. The facility documented continued supervision on 02/20/12 at 7:00 AM through 02/23/12 at 3:00 PM when the facility transferred Resident #1 to the psychiatric hospital. A review of the nurse's notes, dated 03/05/12 at 3:45 PM, revealed the facility readmitted Resident #1 from the psychiatric hospital. However, there was no evidence the facility provided one to one supervision upon the resident's return to the facility even though the facility's established care plans detailed that they would provide one to one supervision and continue all other interventions which the facility had previously documented ineffective results related to "offer diversional activities" and "monitor closely." A review of the March 2012 BOP report revealed the facility's care planned interventions were not effective in managing the resident aggressive behaviors. On 03/05/12, 03/06/12, 03/07/12, 03/12/12, and 03/13/12, the facility documented Resident #1 exhibited behaviors to include verbal abuse with behavorial symptoms and review of the Behavioral Management Log revealed the same type of behaviors on corresponding days. Observation, on 03/16/12 at 10:30 AM, revealed Resident #1 was standing in the hallway near Resident #4's room, whom Resident #1 had previously assaulted on 02/19/12. There was no facility staff supervision for Resident #1 and he/she was able to wander anywhere in the facility. An observation, on 03/16/12 at 3:23 PM, revealed Resident #1 was sitting on the side of his/her bed. Interview with Resident #1 revealed "I'm not here just for the love making, my fiance'..." (the remainder of the conversation was not understandable). Resident #4 had ambulated to Resident #1's doorway and after Resident #1 visualized Resident #4, he/she immediately stiffened in posture and sat on the edge of the mattress, pointing his/her finger, and began to speak loudly stating, "this is a (man's/woman's) room, ..., (resident #4) can't be here." Resident #4 was immediately redirected away from the room of Resident #1. As Resident #4 walked away, Resident #1 continued with pressured speech which continued to increase in volume. There was no facility staff supervision for Resident #1 during this observation. A review of the March 2012 BOP report from revealed the facility's care planned interventions were not effective in managing the resident aggressive behaviors. On 03/21/12, the facility documented Resident #1 exhibited behaviors to include verbal abuse with behavorial symptoms and review of the Behavioral Management Log revealed the same type of behaviors on corresponding days. An interview with the Social Services Director, on 03/21/12 at 6:25 PM, revealed Resident #1's behaviors were addressed with re-education by speaking to him/her. The success rate of the re-education may not be for more than 15 minutes, but was considered effective. She further stated there were 9 or 10 additional residents in the facility with behaviors, comparable to those of Resident #1, and she was the only Social Services personnel and unable to meet the needs of all 63 residents. Further interview with the Social Services Director, on 03/22/12 at 12:05 PM, revealed she had no comprehensive knowledge of Resident #1's [DIAGNOSES REDACTED]. The facility provided no specific behavioral training related to Resident #1's [DIAGNOSES REDACTED]. The Social Services Director stated that the psychiatrist was not invited to the Interdisciplinary Team (IDT) meetings and was not asked to provide any behavioral training for staff related to Resident #1's Intermittent Explosive Disorder and/or Schizoaffective Disorder. An interview with Resident #1's attending psychiatrist, on 03/21/12 at 12:08 PM, revealed the psychiatrist did not receive notification from the facility related to the physical altercation between Resident #1 and Resident #4, and between Resident #1 and Resident #5 on 02/19/12. An interview with the Administrator, on 03/21/12 at 11:55 AM, revealed she was not knowledgeable of the potential dangers associated with persons diagnosed with [REDACTED]. She had not invited the psychiatrist to the behavioral committee meetings nor had he participated in the IDT meetings. There has not been any specific behavioral training related to Resident #1's diagnoses. The facility was unable to provide evidence that they had identified the need to provide supervision of Resident #1 in order to manage his/her aggressive behaviors and to protect other residents from Resident. 2. An interview with the Administrator (a certified nutritionist), and the Director of Nursing (DON), on 03/16/12 at 4:00 PM, revealed mechanically altered diet meant the food was to be "put through a machine," no raw vegetables, very soft bread, crackers and toast was acceptable, and that "when put in the mouth would become soft" and total assistance meant "fed by staff." Interview with the Dietary Manager (DM), on 03/15/12 at 3:55 PM, revealed the facility process for checking therapeutic diet consistency started in the kitchen as a three layer check by the cook, the kitchen aide and the Dietary Manager. The final check is performed by the staff person serving the tray (usually a CNA) to verify that the food on the tray was correct before serving it to the resident. A record review revealed the facility admitted Resident #3 on 05/08/07 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A review of the quarterly MDS assessment, dated 01/01/12, revealed the facility assessed the resident to require extensive assistance of one person physical assistance for eating. A review of the plan of care, dated 01/01/12, revealed Resident #3 was to be "totally fed by staff." A review of the nurse's notes, dated 01/22/12 at 6:05 PM, revealed documentation by Registered Nurse (RN) #1 to include "Notified by Certified Nurse Aide (CNA) that resident was choking. Ran down to room, resident ashen in color. Unable to breath, no air movement to lungs. Heimlich Maneuver done, coughed up large piece of bologna." An interview with the Dietary Manager, on 03/15/12 at 3:55 PM, revealed a sandwich was the substitute on 01/22/12, and someone must have provided a sandwich to Resident #3. An interview with CNA #1, on 03/16/12 at 2:30 PM, revealed, during the supper meal on 01/22/12, she had provided Resident #3 his/her supper tray and left the room to feed other residents. When she returned to the room, Resident #3 was choking on a piece of bologna he/she had fed to himself/herself. CNA #1 revealed the resident had one half of a bologna sandwich and the bologna had been a solid piece. An interview with RN #1, on 03/16/12 at 2:15 PM, revealed during the supper meal on 01/22/12 CNA #1 came to the nursing station and reported Resident #3 was choking. She ran to the resident's room and Resident #3 was not getting any air and she performed the Heimlich Maneuver. The resident coughed up a blob that had bread and a piece of bologna about the size of a fifty-cent piece. RN #1 did not recall if the resident was supposed to be fed by staff and stated the CNAs were to follow the care plan related to feeding. A review of the facility's investigation report, dated 01/22/12, revealed the incident as "choking on food" and the action/intervention taken to prevent/reduce happening again as "close observation while eating" and "dietary to spread meat on bread." The resident's care plan for "At risk for choking" revealed an intervention, dated 01/22/12, which stated "staff to monitor resident closely for choking." The investigation did not identify that staff was not providing t

Based on interview, record review and review of the Administrator's Job Description, 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 for seven residents (#1, #2, #3, #4, #5, #6, and #7), in the selected sample of seven residents. The facility failed to effectively monitor a new system to ensure residents that required mechanically altered food received the appropriate food form to meet the resident's individual needs and diet order and failed to ensure assistance/supervision with feeding was provided for two residents (#2 and #3) in the selected sample of seven to correct identified quality deficiencies related to choking. On 01/22/12, the facility staff served a bologna sandwich to Resident #3 which was not mechanically altered in the appropriate food form. The facility staff witnessed the resident choking, unable to breathe, having no air movement to the lungs and ashen in color. The facility staff had to perform the [MEDICATION NAME] Maneuver. The facility down-graded the resident's diet to pureed meat; however, on 03/15/12, the facility staff was observed serving Resident #3 meat that was not pureed. The facility was knowledgeable of Resident #2's physician order for [REDACTED].#2 meat that was not mechanically altered to the appropriate food form for the resident's needs. The facility staff witnessed the resident choking, face turning red and had to perform the [MEDICATION NAME] Maneuver. The facility had assessed and care planned Resident #1 for aggressive behaviors, however, failed to protect four residents (#4, #5, #6 and #7), in the selected sample of seven from physical and mental abuse from Resident #1. On 01/20/12, Resident #1 made threats of harm toward Resident #7. On 02/08/12, the facility received an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible. Resident #7 was fearful of Resident #1 and told a Certified Nurse Aide (CNA) and Registered Nurse (RN) that he/she wanted to be moved to another room, away from Resident #1, who was threatening him/her. On 02/11/12, Resident #1 physically attacked a staff member throwing him/her on the bed and kicking his/her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #4, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 had substantial bruising to his/her bilateral hands and CNA #9 reported that Resident #4 was "really afraid" after the altercation and that he/she was screaming, crying, trembling, and pacing the floor all night after the altercation. Further review of Resident #4's nurses' notes, on 02/19/12 at 4:55 PM, revealed Resident #4 stated "I need a gun." RN #1 determined Resident #5 had no physical injuries; however, CNA #9 reported that Resident #5, who was wheelchair bound, refused to come out of the safety of his/her room for the remainder of the night after the altercation. The facility failed to identify Resident #1's aggressive and escalating behaviors toward other residents as a trend requiring reassessment and new interventions and supervision in an effort to protect residents residing in the facility. The facility failed to thoroughly investigate an allegation of abuse. It was reported that Resident #1 struck Resident #7 on the head with a Bible. Resident #7 made this verbal report of physical abuse to the staff. Resident #7 was transferred to another room; however, no investigation was completed about the reason why the resident requested a room transfer. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6 and the facility failed to address Resident #1's verbally aggressive behaviors. The facility failed to supervise Residents #4 and #5, who were physically and mentally abused by Resident #1. Resident #1 pinned Resident #4 to the wall in the hallway, which was not witnessed, and after staff responded to the yelling, Resident #1 attempted to pull Resident #5 out of his/her wheelchair. Resident #5 was a bilateral hip level [MEDICAL CONDITION]. There was no evidence the facility followed the "Abuse, Neglect and Exploitation" policy and procedure, related to thoroughly investigating allegations or suspicions by the Support Coordinator and/or their designee. Residents with needs and behaviors which might lead to conflict or neglect were identified, assessed, and a care plan was developed. These residents were monitored and reassessed according to their needs. The facility failed to ensure appropriate food form per their diet orders were served to two residents as per the Academy of Nutritional Dietetics, which was their reference for standards of practice. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 03/21/12 and determined to exist on 01/22/12 and on 02/08/12. Substandard Quality of Care was identified to exist at 483.13, 483.15 and 483.25. Refer to F223, F225, F226, F250, F323, F365 and F520. Findings include: A review of the facility Administrator's Job Description, signed by the Administrator on 04/29/11, revealed listed duties included: works in conjunction with regulatory officials to ensure the safety, health, quality of life and quality of care for individuals residing within the facility. 1. A record review revealed the facility admitted Resident #1 on 04/07/06 with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment, dated 11/28/11, revealed Resident #1 was cognitively alert, and participated in the assessment and goal setting process for care. The Behavior Management Log, dated February 2012, revealed verbally abusive behaviors nine out of twenty-nine days, Physically abusive behaviors two out of twenty-nine days, and socially inappropriate/disruptive behaviors eighteen out of twenty-nine days. The documented resident response revealed the staff interventions were of "little success" or "no success." An interview with Resident #1's Psychiatrist, on 03/21/12 at 12:08 PM, revealed he saw Resident #1 on a regular basis at the facility. The facility did not notify the Psychiatrist about the altercation on 02/19/12. Resident #1 was described by the Psychiatrist as able to demonstrate cognitive orientation through knowledge of current events and acted immediately on his/her thoughts when angry without regard for consequences. The psychiatrist was not contacted by the facility in regard to altercations involving Resident #1 on 01/20/12, 02/11/12, 02/14/12, or 02/19/12. The psychiatrist described Resident #1 as classic Intermittent [MEDICAL CONDITION] and reported the disorder to be genetic. The psychiatrist further reported Intermittent [MEDICAL CONDITION] as a frequently missed [DIAGNOSES REDACTED]. Resident #1 was described as being able, at times, to communicate and demonstrate cognitive orientation through knowledge of the United States President, the Vice President, and the Governor of Kentucky, and other times be out of control and unable to communicate. The resident did not make plans or plot to hurt others, but acted immediately on his/her thoughts when angry without regard for consequences. The psychiatrist described explosive behavior as an "all out" aggression when ticked off. The psychiatrist stated Resident #1 meant to hurt others when he/she exploded and acted on his/her anger. An interview with a Non-Facility Provider, on 03/20/12 at 12:05 PM, revealed that Resident #7 informed him/her on two occasions of being "tired of that (resident)." He/she reported to the facility that Resident #1 and Resident #7 had "heated words," and an inability to get along with each other. He/she further revealed that Resident #7 told him/her that Resident #1 had struck him/her on the head with a Bible. He/she made this verbal report of physical abuse to Facility Staff #1. An interview with Facility Staff #1, on 03/20/12 at 12:15 PM, revealed the conversation with the Non-Facility Provider reported that Resident #7 voiced he/she was unhappy with his/her roommate and desired a room change. The information was presented at the morning meeting. An interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed Resident #7 requested a room change and was moved, on 02/08/12, as a result of the information presented in the morning meeting. While facility staff were made aware of the allegation of abuse, there was no evidence the facility initiated an investigation or provided protection to the other residents of the facility from the alleged perpetrator (Resident #1). Further interview with the Social Services Director, as well as a review of the social services e-mail notification to the county representative for the Department of Aging and Independent Living (DAIL), revealed the facility completed a room change for Resident #7 without an investigation into the reason behind the requested room change. A review of an investigation worksheet, dated 02/14/12, revealed Resident #1 had a verbal confrontation with Resident #6 which necessitated a room change for Resident #6. While the facility initiated a room change for Resident #6, a review of the care plan after this incident, revealed the facility made no changes to address the resident's verbally aggressive behaviors, nor made revisions to the interventions in an effort to manage the behaviors and/or ensure protection of other residents in the facility. There was no evidence the facility identified Resident #1's behaviors as abusive. A review of the nurse's notes and the investigation worksheet, dated 02/19/12, revealed facility staff heard a commotion and found that Resident #1 had "pinned" Resident #4 with his/her face to the hallway wall, and Resident #1 had restrained both of Resident #4's wrists with his/her hands. The facility staff separated Resident #1 and Resident #4, at which time Resident #1 immediately turned and grabbed Resident #5's clothing. Resident #5 was wheelchair bound, having had a bilateral hip level amputation. Resident #1 attempted to pull Resident #5 from his/her wheelchair. The facility staff escorted Resident #1 to the facility's UK Den at which time the facility notified the police. An interview with the police, on 03/21/12 at 11:00 PM, revealed the incident was considered a fourth (4th) degree assault. Further record review revealed the facility assessed Resident #4 and found the resident had substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety. A review of the nurse's notes revealed "Resident afraid. Told me (he/she) was afraid of 'the (resident)' and stated (he/she) needed a gun." Additionally, an interview with CNA #9 revealed, on 03/16/12, that Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident. An interview with the Administrator, on 03/15/12 at 2:00 PM, revealed her knowledge of the facility's policy/ procedure on "Resident Abuse, Neglect and Exploitation," dated 02/07/12, included staff were to report incidents immediately after ensuring resident safety. Any staff to resident alleged abuse or neglect would result in immediate suspension of the employee until the investigation was complete. Resident to resident altercations would involve separation of the residents with appropriate notification to the Office of Inspector General and other required agencies. She expected the staff to follow the facility's policy/procedure for abuse and neglect. A Nurse Aide registry and criminal background check were completed prior to hiring staff. Abuse inservices were completed annually, or anytime there was an incident. Further interview with the Administrator, on 03/16/12 at 9:20 AM, revealed Resident #1 had alarms for awhile but he/she "tore them up" and they were removed due to being ineffective. The Administrator stated staff were "not documenting well," and "if not documented was considered not done." The Administrator revealed, on 03/22/12 at 11:55 AM, she had not done an in-depth research on Resident #1's [DIAGNOSES REDACTED]. Some staff were trained in Behavioral Management and Crisis Prevention Intervention (CPI) with specific behaviors, but only named behaviors related to Dementia. She stated she felt the Psychiatrist would provide training for the staff; however, the Psychiatrist had not been asked to provide training. 2. A record review revealed the facility admitted Resident #2 on 04/10/08 with [DIAGNOSES REDACTED]. He/she was care planned for independent eating with supervision. A review of a physician's order revealed the resident was on a mechanically altered diet. On 02/26/12 at 12:00 PM, the resident was unable to breath, with a very red face. The [MEDICATION NAME] Maneuver was performed and an excessive amount of pulled meat was removed from the resident's mouth, and pulled meat was observed on the food tray. On 02/26/12, the cook was given a second step written warning listing "Did not follow recipe or doctor's order" and the supervisor statement was "Mechanical soft meat has to be mechanically put in a machine and ground for texture." A record review revealed the facility admitted Resident #3 on 05/08/07 with [DIAGNOSES REDACTED]. A review of a physician's order revealed the resident was on a mechanically altered diet. On 01/22/12 at 6:05 PM, the resident was found choking on a bologna sandwich and required an intervention of the [MEDICATION NAME] Maneuver. Dietary staff was inserviced to ensure meals served were accurate and to spread meat on bread for mechanically altered diets. An interview with Certified Nurse Aide (CNA) #1, on 03/16/12 at 2:30 PM, revealed she served Resident #2's supper meal, on 01/22/12, and left the room to feed other residents. When she returned to the room, Resident #3 was choking on a piece of bologna he/she had fed to himself/herself. CNA #1 revealed the resident had one-half of a bologna sandwich and the bologna was a solid piece. Resident #2 and Resident #3 required an intervention of the [MEDICATION NAME] Maneuver when they were served food not mechanically altered as per their physician ordered diets. On 03/15/12, during an observation of the meal service, Resident #3 was in his/her room unsupervised, prepared to eat with a spoon in his/her hand. The diet card revealed Mechanically Altered Pureed Meat. Further observation revealed the meat on the tray was not pureed. There was a hot dog bun cut in sections with chili which contained chunks of ground beef and chunks of a hot dog. Interview with CNA #2, on 03/16/12 at 12:30 PM, revealed there were chunks of ground beef and hot dog on Resident #3's lunch tray, on 03/15/12. She stated she picked the chunks out of the pureed meat and the lunch meal usually had chunks in the pureed meat. Interview with CNA #3, on 03/16/12 at 11:55 AM, revealed she served Resident #3's lunch tray, on 03/15/12, and left the room because she understood that the resident fed himself/herself and staff assisted him/her to finish the meal. An interview with the Administrator, on 03/16/12 at 7:55 AM, revealed she was unable to explain how Resident #3 received a tray of food which was not in the appropriate food form for the mechanically altered diet the resident was supposed to receive per their policy, despite having initiated a new system to ensure residents requiring mechanically altered meals received the appropriate food form to prevent potential choking episodes.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to ensure residents received adequate supervision to prevent resident to resident abuse and ensure residents received the appropriate form of diet according to residents individual needs. However, non-compliance continued to exist at a S/S of a "E" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and the facility had not had an opportunity to develop and implement a Plan of Correction (POC), related to residents receiving adequate supervision to prevent resident to resident abuse and ensuring residents received the appropriate form of diet according to residents individual needs. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the Minimum Data Set (MDS) Coordinator reviewed and revised the Behavior Observation Program (BOP) sheets and the nurse aide care plans for all residents on 03/29/12. The revisions included interventions specific to each resident with a sticker placed on the BOP sheet as a reminder of the suggested interventions. Further, training was completed on 03/29/12, for all nursing staff and new hires during orientation regarding appropriate documentation on the Behavior Management Log to indicate resident responses to interventions attempted. In an instance of unsuccessful attempts, the nursing staff are to notify the charge nurse for assessment of the need for 1:1 supervision. Resident #2 and Resident #3 were placed on one to one supervision for all meals and snacks. All resident dietary care plans were reviewed and revised by the Registered Dietitian (RD) or Certified Nutritionist (CN) on 03/29/12. A comparison between the physician's orders [REDACTED]. A daily review with updates as needed was performed by the Registered Dietitian and/or the Certified Nutritionist. Resident meal/tray observations were initiated on 03/21/12 for all resident diets at the point of tray origin for all meals. Supervised dining was initiated on 03/17/12 for all residents requiring assistance of feeding. An additional dining room was set up on 03/16/12 for all resident who required assistance with feeding. Those residents identified for high risk were supervised one to one with feeding. All dietary staff and staff members were educated on Modified Textured Diets on 03/28/12 and 03/29/12. A pre-test and post-test was administered. Modified texture diet trays are checked by a licensed staff member prior to serving to ensure the residents are receiving the appropriate diet. This will continue for 30 days and reports are communicated to the DON for review and then the Administrator by the DON. A report is then communicated to the Corporate compliance Nurse daily by the Administrator. Any problems identified were corrected immediately. A system has been established for charge nurses to report, on a daily basis, any dietary care plan changes not made by the RD or CN to the DON who would then report the changes to the RD or CN for review. A daily report was made to the Corporate Compliance Nurse detailing dietary care plans and diet orders. Snacks are reviewed by the Certified Medication Aides (CMA's) and monitored by the CMAs with documentation provided to the DON daily. The DON provides communication to the Administrator daily. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to implementing the facility's policy and procedure on resident to resident abuse. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to the implementation of the facility's policy and procedure which addressed abuse prevention, identification, intervention, and reporting. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed training by the Corporate Compliance Nurse identified the Administrator as the person responsible to ensure there is sufficient and adequate investigation and reporting of all incidents and allegations related to the facility's abuse policy and procedure. In-services covering the facility's Abuse, Neglect, and Exploitation policy and procedure were provided for all administrative personnel and facility staff to include detailed information on appropriate interventions, reporting allegations, reorganization of abuse, and the investigation required. A system has been established involving the Corporate Compliance Nurse receiving a written report from the Administrator on a daily basis to monitor alleged violations related to abuse, neglect, or mistreatment of [REDACTED]. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview, record review and review of the facility's policy and procedure, it was determined the facility failed to operationalize policies and procedures for protection of three residents (#4, #5 and #7), in the selected sample of seven residents, from abuse by Resident #1. The facility failed to follow its' policy/procedure related to resident abuse, neglect and exploitation. The facility failed to first assure resident's safety and protection followed by a thorough examination, incident documentation, notification of attending physician with treatment provided per physician's orders [REDACTED]. The facility failed to identify the Resident #1's personal history, diagnoses, and the facility's assessment of Resident #1, as factors that could render him/her to be a risk for abuse toward other residents. Staff interviews revealed they knew they should not turn their back to Resident #1 due to his/her history of violence toward other residents and staff. Resident #1's attending psychiatrist detailed Resident #1 was known to demonstrate classical Intermittent [MEDICAL CONDITION] and described these behaviors as unpredictable for the intensity of the violence and that the actions are not planned, but willful, as the anger is demonstrated in "all-out" aggression. On 01/20/12, Resident #1 made threats of harm toward Resident #7. On 02/08/12, the facility received an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible. On 02/11/12, Resident #1 physically attacked a staff member throwing her on the bed and kicking her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #4, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. The facility could provide no evidence detailing that they identified Resident #1's behaviors as a risk for potential abuse, initiated an investigation after each incident or implemented interventions to protect other residents from further potential abuse. While the facility had assessed, care planned, and logged Resident #1's aggressive behaviors, there facility staff documented the interventions were unsuccessful; however, there was no evidence the facility initiated any new interventions. Prior to exit, the facility did not submit an Allegation of Compliance for the removal of Immediate Jeopardy. The facility's failure to follow their abuse policy/procedure regarding identifying Resident #1's aggressive behaviors as having the potential and risk for abuse to other residents, not investigating incidents and not providing appropriate supervision and protection for Residents caused harm for Resident #7, #4, and #5 and is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 02/08/12 and is ongoing. Findings include: A review of the facility's policy/procedure, "Resident Abuse, Neglect and Exploitation," revealed the resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation, and injuries of unknown origin. The policy detailed the facility will first assure resident's safety and protection followed by a thorough examination, incident documentation, notification of attending physician with treatment provided per physician's orders [REDACTED]. The residents are monitored and reassessed according to their needs. The staff's role in abuse prevention was training to identify and report inappropriate behaviors such as derogatory language, rough handling, ignoring residents while giving care, direction residents who need toileting assistance to urinate or defecate in their beds, etc. Supervision of this includes but is not limited to compliance rounds. A record review revealed the facility admitted Resident #1 on 04/07/06 with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact and participated in the assessment and goal setting process for care. A review of the Behavior Management Log, dated February 2012, revealed verbally abusive behaviors were present nine days out of twenty-nine days, and physically abusive behaviors were demonstrated two days out of twenty-nine days, and socially inappropriate/disruptive behaviors were demonstrated eighteen days out of twenty-nine days. Review of the logs revealed staff interventions produced little or no success. On 01/20/12, Resident #1 made threats of harm toward Resident #7. Interview with LPN #4, on 03/19/12 at 4:05 PM, revealed that Resident #1 apologized after the incident was over and she thoguht the apology was sincere. However, record review revealed no evidence the facility had investigated the incident related to Resident #1 verbally threatening another resident. There was no evidence the facility reassessed Resident #1 for the aggressive behavior or determined revised the care plan interventions. Furthermore, the facility was unable to provide any evidence that they had initiated any protection for other residents from Resident #1. Interview with the Non-Facility Provider, on 03/20/12 at 12:05 PM, revealed she reported to Facility Staff #1 on 02/08/12 an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible and that Resident #7 wanted a room change. Resident #7's interview, on 03/20/12 at 10:45 AM, revealed Resident #1 hit him/her over the head with a Bible sometime prior to 02/08/12. He/she stated that he/she wanted to be moved due to the threatening behaviors of Resident #1. While the facility noted in the Nurses' Notes and Social Services Notes on 02/08/12 that they transferred Resident #7 to another room, per his/her request, there was no evidence the facility initiated an investigation into the allegation. Furthermore, there was no evidence the facility initiated protection of residents of the facility from the behaviors exhibited by Resident #1. Interviews with CNA #5, on 03/20/12 at 5:19 PM and CNA #6 at 2:05 PM, revealed on 02/11/12, Resident #1 physically attacked a staff member throwing her on the bed and kicking her head into the footboard of the bed, then threw his/her walker at another staff member. Interview with LPN #4, on 03/20/12 at 3:20 PM, revealed the facility did not document the incident, they just discussed it in shift report. The facility could provide no evidence that they investigated the incident, assessed Resident #1 for the physically abusive behaviors, identified potential risk for further abusive acts or implemented measures to provide protection to other residents of the facility. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. Review of the facility's investigation worksheet, dated 02/14/12, revealed Resident #1 had a verbal confrontation with Resident #6 which necessitated a room change. However, there was no evidence the facility reassessed Resident #1 for his/her behaviors, revised the care plan to address behavior techniques changes, or initiated protective measures to ensure the safety of the residents of the facility. Review of the nurse's notes and the investigative worksheet, dated 02/19/12, revealed staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #4, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. An interview with the police, on 03/21/12 at 11:00 PM, revealed the incident was considered fourth (4th) degree assault. The facility initiated one to one supervision after the incident and transferred the resident out to the psychiatric hosptial on 02/23/12. The facility readmitted Resident #1 on 03/05/12; however, there was no evidence the facility continued one to one supervision of the resident to ensure the protection of the residents of the facility. Furthermore, review of the medical record revealed no new interventions or assessment was conducted to address the resident's escalating aggressive behaviors resulting in harm to multiple residents of the facility. Observation, on 03/16/12 at 10:30 AM, revealed Resident #1 was standing in the hallway near Resident #4's room, whom Resident #1 had previously assaulted on 02/19/12. There was no facility staff supervision for Resident #1 and he/she was able to wander anywhere in the facility. Observation, on 03/16/12 at 3:23 PM, revealed Resident #1 was sitting on the side of his/her bed. Interview with Resident #1 revealed "I'm not here just for the love making, my fiance'..." (the remainder of the conversation was not understandable). Resident #4 had ambulated to Resident #1's doorway and after Resident #1 visualized Resident #4, he/she immediately stiffened in posture and sat on the edge of the mattress, pointing his/her finger, and began to speak loudly stating, "this is a (man's/woman's) room, ..., (resident #4) can't be here." Resident #4 was immediately redirected away from the room of Resident #1. As Resident #4 walked away, Resident #1 continued with pressured speech which continued to increase in volume. There was no facility staff supervision for Resident #1 during this observation. An interview with Licensed Practical Nurse (LPN) #1, on 03/18/12 at 7:03 PM, revealed Resident #1 was known to be aggressive with the staff and residents, and if fixated on something, he/she could not be redirected and "would pray for the best." An interview with CNA #4, on 03/19/12 at 3:30 PM, revealed Resident #1 had behaviors every day, he/she "fussed and cussed" and after a while "you get used to it." The behaviors were documented on the BOP sheets every shift. An interview with the Administrator, on 03/17/12 at 9:30 AM, revealed Resident #1 was not new to the facility and the solution was to take him/her to the sensory room because it was effective, and he/she liked to be with others, as well as being a calm environment for Resident #1. The Administrator described Resident #1 as "difficult" and an "intimidator," and felt relocating roommates in the past helped the situation. Staff was aware to watch Resident #1 and deal with behaviors daily. The Administrator reported behavior management training was provided to staff with a focus on the Crisis, Prevention, and Intervention (CPI) program with additional workshops on general behaviors to include dementia. She revealed that the staff doesn't take credit for use of CPI interventions because it wasn't successful for more than a short time. On 03/22/12 at 11:55 AM, the Administrator revealed the facility had not completed any in depth research on the [DIAGNOSES REDACTED].#1. Although, he/she reported staff had limited training for generalized behaviors, they had no training for Resident #1's specific [DIAGNOSES REDACTED]. She stated resident to resident altercations would involve separation of the residents with appropriate notification to the Office of Inspector General and other required agencies. She expected the staff to follow the facility's policy/procedure for abuse and neglect.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to implementing facility's policy and procedure on investigation and reporting of alleged resident to resident abuse. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to the investigation and reporting of resident to resident abuse. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the Corporate Compliance Nurse trained the Administrator, on 03/21/12, that all alleged violations involving mistreatment, neglect or abuse must be reported to other officials such as the DCBS and OIG. There must be evidence that all alleged violation are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. It is the responsibility of the Administrator to ensure sufficient and adequate investigation and reporting are accomplished. It was determined all residents were potentially at risk for abuse and all residents were observed and interviewed by licensed nursing staff related to abuse. A system of reporting had been established beginning with nurse aide hourly rounds and charge nurse compliance rounds completed twice each shift. The nurse aide hourly reports were passed to the charge nurse for review at the end of each shift, with the exception of any problems which were reported immediately to the charge nurse. The information gained during the charge nurse compliance rounds was given to the DON during the week days and to the Administrative nurse on the weekend days. Any problems were immediately reported to the DON, the Administrator, and the Corporate Compliance Nurse. The Corporate Compliance Nurse was receiving a written report from the Administrator on a daily basis to monitor alleged violations related to abuse, neglect, or mistreatment of [REDACTED]. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to resident to resident abuse. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and the facility had not had an opportunity to develop and implement a Plan of Correction (POC), as related to abuse prevention, identification, intervention, and reporting. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the Corporate Compliance Nurse and facility Administrator provided an in-service on 03/21/12 for the Administrative nurses, the Social Services Director, and other facility Supervisors/ Department leaders with the focus being the facility's Abuse, Neglect, and Exploitation Policy with in-depth coverage on abuse recognition, reporting allegations and incidents, appropriate interventions, and the investigation process. All remaining staff and new hires were in-serviced by 03/22/12. Nurse aide rounds, in-serviced and initiated on 03/21/12, were completed every hour with a designated sheet for documentation and reporting to the charge nurse. The facility cited the reason was to view residents frequently, know their whereabouts, and assess the environment for accident hazards and maintaining a safe environment. Additionally, the hourly rounds included observing for indicators of abuse or potential abuse. The charge nurses conducted compliance rounds twice each shift to observe for indicators of abuse and to confirm a safe environment. Documentation of the compliance rounds was in a check sheet format and any items identified were addressed immediately with a written report that was passed on to the DON, who reports to the Administrator, who reports to Corporate Compliance Nurse. A system for daily monitoring of incident reports covers 7 days a week and was reviewed by Administrative nurses with any problems immediately passed on to the Administrator and Corporate Compliance Nurse. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on observation, record review, interview, and review of the Social Services job description, the facility failed to ensure appropriate and timely social services for four residents (#1, #5, #6, and #7), in the selected sample of seven residents, related to behaviors that could adversely affect other residents, and assessing the need for social services interventions. The facility failed to ensure they had an effective system to manage residents aggressive behaviors and implement effective interventions to meet the individual needs of each resident and protect other residents from harm. The facility failed to ensure social service staff was knowledgeable in behavior management of residents' with psychiatric [DIAGNOSES REDACTED]. The resident's Psychiatrist described his/her explosive behavior as "all out aggression when ticked off, stating Resident #1 means to hurt another person when he/she explodes and acts on his/her anger. On 01/20/12 at 3:00 AM, Resident #1 verbally threatened physical harm to Resident #7. At 4:00 AM, Resident #1 continued to threaten Resident #7. On 02/0812, the facility became aware of an allegation of physical abuse alleging Resident #1 hit Resident #7 over the head with a bible. On 02/11/12, Resident #1 physically assaulted two (2) CNAs as they attempted to prepare the resident for bed, flipping one CNA onto the bed, kicked the CNA's head into the footboard. On 02/14/12, Resident #1 was verbally aggressive towards Resident #6. On 02/19/12, Resident #1 pinned Resident #4 to the wall in the hallway causing substantial bruising to bilateral hands of Resident #4 then he/she attempted drag Resident #5, who had bilateral above the knee amputations, from the wheelchair. The facility failed to ensure social services reassessed Resident #1 for the persistent aggressive behaviors and implemented new interventions, once the facility staff documented the interventions were ineffective. Additionally, the facility failed to ensure Resident #1's psychiatrist was made aware of the escalating behaviors and utilized for assistance with behavior management. This failure prevented the facility addressing the individual resident's behavioral needs and prevented the facility from implementing interventions to protect residents from harm. Observation and record review identified that on 03/16/12 the facility had not put in measures to address the resident's aggressive behaviors that led to physical attacks to Residents #7, #4, and #5; however, allowed the resident access to other residents of the facility without supervision. The facility failed to ensure Resident #5's behaviors were being managed and failed to address Resident #5's fear of leaving his/her room after the incident with Resident #1. This failure to update and effectively utilize the care plan resulted in harm to three residents. The facility's job description for Social Services defines job duties as patient counseling, reporting complaints and suggesting remedies, and participation in Patient Care Planning. Prior to 02/20/12 there is no evidence of effective social services interventions through notification of the attending physician, resident assessment, staff training, investigation of resident complaint, or care plan changes related to the escalating behaviors of Resident #1. Prior to exit, the facility had not provided an Allegation of Compliance to remove Immediate Jeopardy. This failure resulted in Immediate Jeopardy and Substandard Quality of Care having caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 01/22/12 and is ongoing. (Refer to F223, F226, F280 and F323) Findings include: A review of the facility's job description for social services revealed the responsibility for fulfillment of patient's basic psychosocial needs in the preparation and participation of Patient Care Plan conferences, recording and reporting complaints with suggested remedies, and counseling patients. The Social Services Plan of Care was to be integrated into the residents' comprehensive Plan of Care. The Plan of Care was to be developed with a comprehensive assessment and would reflect the residents' individual needs and promotion of social well being. An interview with the DON, on 03/21/12 at 4:15 PM, revealed the Social Services Director (SSD) looked at anything related to behaviors. The SSD gained information for individual resident care plans from review of Behavior Observation, Side Effect Monitoring and Delirium (BOP), care plans, a general assessment and by attending meetings to include the daily morning meetings, the monthly Behavior meetings, and the quarterly Interdisciplinary Team meetings. Discussion of behaviors and resident concerns was done in the daily morning meetings. The Social Services Director was responsible for evaluating the behavioral information gathered from these meetings and to implement individualized behavioral interventions for each residents' plan of care according to the residents' individualized needs at the time of behavioral changes. She revealed the facility utilizes the Crisis Prevention Institute (CPI) program which focuses primarily on verbal cues and if escalation occurs staff escort the resident. Currently, all staff have not been trained on CPI. The facility does not have a behavior modification program rather a behavior management program so each behavior can be addressed as they manifest. No PRN ("as needed") medications are given without approval from the DON but one to one supervision was used as a nursing intervention implemented at any time it was appropriate. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as cognitively intact and participated in the assessment and goal setting process for care. The facility initiated a Behavior Care Plan dated 11/23/11 which revealed staff was to "offer diversional activities" and "monitor closely." Nurses notes, dated 01/20/12 at 3:00 AM, revealed facility staff found Resident #1 cursing roommate Resident #7 while he/she slept and Resident #1 continued to verbally threaten the roommate even after attempts of diversional activities by staff. An additional note dated -1/20/12 at 4:00AM, further revealed Resident #7 was out of the room yet Resident #1 continued to curse and threaten Resident #7. Review of the BOP report, dated 01/20/12, revealed the facility staff identified Resident #1's behaviors on the evening shift as verbally abusive behaviors that were not easily altered. An interview with CNA #9, on 03/16/12 at 12:30 PM, revealed Resident #1 was often found standing over Resident #7 while he/she slept. On 01/20/12 the same care plan interventions as "offer diversional activities" and "monitor closely" continued with no new interventions added to address the ineffectiveness of the same care plan intervention being utilized both before and after the resident's aggressive behavior. Additionally, there was no evidence Social Services reassessed Resident #1's individualized needs to determine appropriate interventions related to Resident #1's aggressive behaviors related to the resident's diagnoses. Furthermore, there was no implementation of new care plan interventions or supervision to ensure the protection of Resident #7 and other residents of the facility from Resident #1's aggressive and threatening behaviors. Review of the February 2012 Behavior Observation, Side Effect Monitoring and Delirium (BOP) report and the Behavior Management logs revealed on 02/02/12, Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. On 02/04/12, Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate, disruptive behaviors, and sexual comments. On 02/05/12, Resident #1 exhibited behavior symptoms of cursing, yelling, and threatening. On 02/06/12, 02/08/12 Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. There was no documented evidence that Social Services had made revisions to the residents care plan related to modification of interventions for the resident's aggressive behaviors. Interview with Resident #7, on 03/20/12 at 10:45 AM, revealed Resident #1 had struck Resident #7 on the head with a Bible sometime before his/her room transfer on 02/08/12. Resident #7 stated he/she requested a room transfer related to the threatening behaviors exhibited toward him/her by Resident #1. Interview with a Non-Facility Provider, on 03/20/12 at 12:05 PM, revealed that Resident #7 had informed her on two occasions of being "tired of that (resident)". The Non-Facility Provider stated she reported to the facility that Resident #1 and Resident #7 had "heated words" and an inability to get along with each other. She further revealed that she made a verbal report of physical abuse to the Facility Staff #1 regarding Resident #1 hitting Resident #7 over the head with a Bible. Interview with RN #1, on 03/16/12 at 2:25 PM, revealed that Resident #7 had expressed a desire to change rooms and he/she did not like his/her roommate. An interview with CNA #9 on 03/16/12 at 12:30 PM revealed Resident #1 was often found standing over Resident #7 while he/she slept during the time they were roommates. Interview with Facility Staff #1, on 03/20/12 at 12:15 PM, revealed the conversation with the Non-Facility Provider provided the report that Resident #7 was unhappy with his/her roommate and desired a room change. The information was presented at the morning meeting. Interview with the Social Services Director, on 03/20/12 at 9:30 am, revealed Resident #7 had requested a room change and was moved on 02/08/12. While the facility completed the room change for Resident #7, there was no evidence that the facility investigated the allegation of abuse, reassessed Resident #1's behaviors or revised Resident #1's care plan related to increased supervision for the protection of other residents of the facility or manage the resident's behaviors specifically after being informed of the allegation on 02/08/12. The care plan detailed the same care plan interventions that staff would "offer diversional activities" and "monitor closely". The Social Services Director was unaware Resident #7 had been struck on the head by Resident #1 prior to the room change on 02/08/12. Additional interview with the Administrator, on 03/17/12 at 9:30 AM, revealed Resident #1 was an "intimidator" and was overall difficult to manage. Other residents were easily intimated by Resident #1 and the process of moving out his/her roommates reinforced his/her intimidating behaviors. CNA #4, on 03/19/12 at 3:30 PM, reported Resident #1 exhibited behaviors everyday of cursing and ranting continuously, and "you would eventually get use to these behaviors after a while, and it would no longer bother you anymore". Further review of the February 2012 Behavior Observation, Side Effect Monitoring and Delirium (BOP) report and the February Behavior Management Log revealed the resident showed persistent aggressive behavior symptoms including verbal abuse, cursing, yelling, threatening and physical attacks, without the facility staff determining interventions were successful. On 02/09/12, and 02/10/12 revealed Resident #1 presented with behavior symptoms of cursing, yelling, threatening and socially inappropriate and disruptive behaviors. On 02/11/12, Resident #1 exhibited socially inappropriate and disruptive behaviors and verbal abuse. Ther was no evidence social services reviewed and assessed Resident #1's behaviors or modified the care plan to detail a change related to interventions that staff specified was not effective for Resident #1's behavior management or for the supervision to protect other residents. Review of nurse's notes, dated 02/11/12 at 4:30 AM, revealed Resident #1 became upset with staff during Activities of Daily Living (ADL) care and physically assaulted two staff. Attempts to redirect Resident #1 were unsuccessful and staff left the room to report the incident to the charge nurse. This incident was not detailed on the BOP report or Behavior Management Log nor was there an investigation to determine the root cause of the resident's behaviors. There was no documented evidence that social services conducted an assessment or revised the care plan to address Resident #1's behaviors on 02/11/12. Review of nurse's notes, dated 02/14/12 at 12:30 PM, revealed Resident #1 became verbally aggressive toward Resident #6, who was his/her roommate, and Resident #1 was placed on one to one supervision. The facility initiated Close Observation or 1:1 Supervision for Resident #1. Review of the Supervision document dated 02/14/12 revealed Resident #1 was on one to one supervision from 12:30 PM until 11:30 PM. A review of the Investigation Worksheet dated 02/12/12 at 12:30 PM revealed Resident #1 was being verbally confrontational to Resident #7. Resident #1 was placed on 1:1 supervision and the room change for Resident #6 was completed on 02/14/12 at 2:00 PM. The BOP report documented socially inappropriate/ disruptive symptoms and the Behavior Management Log revealed Resident #1 was angry and fighting with roommate. Interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed the room change for Resident #6 was the result of a verbal argument between Resident #6 and Resident #1 on 02/14/12. The facility Interdisciplinary Team and the Power of Attorney (POA) for Resident #6 decided the room change was necessary. A record review of the Social Services notes, dated 02/10/12 with no time indicated, revealed the facility and Resident #6's POA determined it was best to move Resident #6 out, after having been roommates with Resident #1 for only four days. The Social Services notes entry dated 02/14/12 reports Resident #6 was moved out of the room with Resident #1 after four days related to verbal confrontations with one another. Although there was one to one supervision for 11 hours related to the 02/14/11 altercation between Resident #1 and Resident #6, there was no evidence of any further changes made by social services to address Resident #1's aggressive behaviors. The Social Services Director's only response to the necessitated room changes on 02/10/12 and 02/14/12, was that it was due to verbal behaviors between roommates, with "no concerns noted". There was no evidence the facility social services conducted an assessment, increased supervision or revised the care plan. A review of the nurse's notes, dated 02/19/12 at 5:00 PM, the investigation worksheet, dated 02/19/12 at 9:35 PM, and interviews with CNA #9, on 03/16/12 at 12:30 PM, revealed CNA #9 heard yelling and went into the hall and witnessed Resident #1 pushing Resident #4's face up against the wall and restraining his/her hands against the wall. Resident #1 was removed by an employee and Resident #1 grabbed Resident #5 by the clothes and was going to pull him/her out of the wheelchair. It took two (2) staff members to escort Resident #1 away from the scene of the altercation and into the UK Den for de-escalation and one to one supervision. RN #1 assessed Resident #4 and Resident #5 for physical injuries. Resident #4 had substantial bruising to his/her bilateral hands and CNA #9 reported that Resident #4 was "really afraid" after the altercation and that he/she was screaming, crying, trembling, and pacing the floor all night after the altercation. Further review of the Resident #4's nurses' notes, on 02/19/12 at 4:55 PM, revealed Resident #4 stated "I need a gun." RN #1 determined Resident #5 had no physical injuries; however, CNA #9 reported that Resident #5, who was wheelchair bound, refused to come out of the safety of his/her room for the remainder of the night after the altercation. Further review of Resident #1's nurses' notes revealed that RN #1 notified the DON and Administrator, who contacted the local police for assistance. The police officer who responded reported that Resident #1 committed fourth (4th) degree assault. Upon visualization of the police officer, Resident #1 began to scream, complaining of chest pain. RN #1 notified the admitting hospital emergency room staff to give a report on Resident #1's complaints of chest pain and reported her fears that the resident would hurt someone. The facility initated the "Short Term Temporary Care Plan," on 02/19/12, which detailed the altercation with another resident and specified staff would remove residents from the area/situation, notify the Charge Nurse immediately, assess residents for any harm, provide safe environment, notify the physician and responsible party of the incident, and the need for one to one supervision. However, there was no evidence that social services reassessed Resident #1's behaviors and revised the care plan to implement effective interventions to address the resident's escalating aggressive behaviors towards other residents. The facility readmitted Resident #1 from the hospital emergency room , on 02/20/12 at 2:25 AM, and initiated one to one supervision. While the facility implemented one to one observations, there was no documented evidence the social services addressed the Resident's aggressive behaviors and/or revised the care plan with effective behavior management interventions. Further review of the February 2012 BOP reports and Behavior Management Logs revealed On 02/20/12 and 02/21/12, Resident #1 exhibited verbal abuse with behavioral symptoms. However, the documents revealed that none of the facility's interventions were effective related to the resident's behaviors and there was no evidence of that social services reviewed or revised the care plan with new interventions. Review of nurse's notes, dated 02/23/12 at 3:05 PM, revealed Resident #1 was transferred to a psychiatric hospital and returned to the facility on [DATE] at 3:45 PM. There was no evidence the social services assessed Resident #1 upon return to review/revise the care plan with new interventions for effective behavior management. Rather, the facility discontinued providing one to one supervision and social services maintained the same behavior interventions of "offer diversional activities" and "monitor closely" which the facility continued to document as unsuccessful. Observation, on 03/16/12 at 10:30 AM, revealed Resident #1 standing in the hallway to the side of the doorway of Resident #4's room, whom Resident #1 had previously assaulted on 02/19/12. There was no facility staff observed supervising Resident #1 allowing this resident to wander anywhere in the facility. An observation, on 03/16/12 at 3:23 PM, revealed Resident #1 sitting on the side of his/her bed. The conversation began with Resident #1 stating "I'm not here just for the love making, my fiance'..." and the remainder of the conversation was not understandable. Resident #4 ambulated to Resident #1's doorway and after Resident #1 visualized Resident #4, he/she immediately stiffened in posture and popped to the edge of the mattress, pointing his/her finger at Resident #4, and began to speak loudly stating, "this is a (man's/woman's) room, ..., (resident #4) can't be here". Resident #4 was immediately redirected away from the room of Resident #1. As Resident #4 walked away, Resident #1 exhibited pressured speech that continued to increase in volume. There was no facility staff observed supervising Resident #1 at this time. Interview with LPN #2, on 03/21/12 at 5:35 PM, revealed the facility procedure for contacting the attending psychiatrist was the charge nurses were not allowed to contact the physician directly. The charge nurse must first contact the administrative nurse on call to establish a true need. The physician was on call 24 hours a day and 7 days a week and when needed, had always been available. When contacted the physician required complete information before providing orders. The physician had not been made aware of the incidents with Resident #1. Interview with the Social Services Director, on 03/21/12 at 6:25 PM, revealed Resident #1's behaviors had been addressed with re-education by speaking to him/her. The success rate of the re-education may not be for more than 15 minutes but is considered effective. She further stated there are 9 or 10 additional residents in the facility with behaviors comparable to those of Resident #1 and she is only one person and unable to meet the needs of all 63 residents. Interview with the Social Services Director on 03/22/12 at 12:05 PM, revealed she did not have comprehensive knowledge of Resident #1's [DIAGNOSES REDACTED]. The facility had provided no specific behavioral training related to Resident #1's [DIAGNOSES REDACTED]. It was further stated that the psychiatrist was not invited to the Interdisciplinary Team (IDT) meetings and had not been asked to provide any behavioral training for staff related to Resident #1's Intermittent Explosive Disorder and/ or Schizoaffective Disorder. An interview with the psychiatrist, on 03/21/12 at 12:08 PM, revealed he/she was familiar with Resident #1 since 2008 and sees the resident on a regular basis in the facility. The psychiatrist was not contacted by the facility in regard to altercations involving Resident #1 on 01/20/12, 02/11/12, 02/14/12, or 02/19/12. The psychiatrist described Resident #1 as classic Intermittent Explosive Disorder and reported the disorder to be genetic. The psychiatrist further reported Intermittent Explosive Disorder as a frequently missed [DIAGNOSES REDACTED]. Resident #1 was described as being able, at times, to communicate and demonstrate cognitive orientation through knowledge of United States President, Vice President, and Governor of Kentucky and other times be out of control and unable to communicate. The resident does not make plans or plot to hurt others but acts immediately on his/her thoughts when angry without regard for consequences. The psychiatrist described explosive behavior as "all out aggression when ticked off. The psychiatrist stated Resident #1 means to hurt another person when he/she explodes and acts on his/her anger. According to interview with the DON, on 03/21/12 at 4:15 PM, it was the responsibility of the Social Services Director to review the BOP, the nurse's notes, the daily sheet, and Behavior Management Log, due to his/her failure to effectively evaluate this data, there was no identification of Resident #1's escalating behavior or the need for increased supervision. She further stated that while the facility utilizes the CPI program, not all staff have not been trained on CPI. Furthermore she revealed that no special training has been provided to assess the effectiveness of CPI or nursing interventions. The DON stated the psychiatrist had not been notified, requested to attend the facility's behavioral meetings nor participated in the IDT meetings related to this resident. The DON revealed that she was not aware if the staff had notified Resident #1's attending psychiatrist of the recent onset and escalation of physically aggressive behaviors. Interview with the Administrator, on 03/17/12 at 9:30 AM, revealed Resident #1's physical behaviors were new and the solution was to take the resident to the sensory room (known as the "UK Den"). Staff was aware to watch Resident #1 and deal with behaviors daily. Resident #1 was described as an "intimidator" and "difficult". The Administrator reported behavior management training was provided to staff with a focus on the Crisis, Prevention, and Intervention (CPI) program with additional workshops on general behaviors to include dementia. She stated she believed it was the staff's responsibility to identify a need for specific behavior management training and ask the administrative nurse to set it up with the psychiatrist. She revealed that the staff doesn't take credit for use of CPI interventions because it wasn't successful for more than a short time. On 03/22/12 at 11:55 AM, the Administrator revealed the facility had not completed any in depth research on the [DIAGNOSES REDACTED].#1 and he/she was unaware if any other residents in the facility had the same diagnoses. Although, he/she reported staff had limited training for generalized behaviors, they had no training for Resident #1's specific [DIAGNOSES REDACTED]. 2) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Short Term/ Temporary Care Plan initiated on 05/16/11 with notations of review/update, continue all approaches on 08/15/11, 11/03/11, and 01/26/12. The care plan revealed a plan for socially inappropriate/disruptive behavior with examples of throwing food trays and destroying property with the stated goal of reduced episodes of socially inappropriate/disruptive behavior over the next 90 days. Review of the BOP report for February 2012 revealed behaviors to include verbally abusive with behavioral symptoms occurring on days 5, 10, 16, 21, and 24. The Behavior Management Log describes verbally abusive with behavioral symptoms as screaming, crying, cursing staff, and yelling on days 5, 7, 8, 10, 11, 13, 16, 20, and 21. Review of the BOP report for February 2012 revealed Socially inappropriate/disruptive and behavioral symptoms occurred on days 5, 7, 8, 9, 10, 11, 12, 15, 16, 20, 21, 22, 23, 24, 25, and 28. The Behavior Management Log describes socially inappropriate/disruptive and behavioral symptoms described as throwing food and liquids occurred on days 7, 8, 9, 10, 11, 13, 21, 22, 23, 24, 25, and 27. Review of the February 2012 Behavior Management Log for physical behaviors to include injury to self on days 8 and 21. On 02/16/12, the Behavior Management Log documents that Resident #5 exhibited behaviors of throwing furniture and running over peers feet with wheelchair. On 02/28/12, the Behavior Management Log detailed Resident #5 exhibited behaviors of flipping the over bed table. The facility staff documented no evidence of success with the facility implemented interventions of verbal cues, reorientation, redirect and comfort measures. Behavioral care plan goals were not met for resident #5 as demonstrated by the ongoing behaviors documented on the BOP reports and Behavior Management Logs. There was no evidence Social Services had re-assess this resident's behaviors to determine more effective interventions for the management of the resident's behaviors. A review of the nurse's notes, dated 02/19/12 at 5:00 PM, the investigation worksheet, dated 02/19/12 at 9:35 PM, and interviews with CNA #9, on 03/16/12 at 12:30 PM, revealed CNA #9 heard yelling and went into the hall and witnessed Resident #1 grab Resident #5 by the clothes and was going to pull him/her out of the wheelchair. It took two (2) staff members to escort Resident #1 away from the scene of the altercation and into the UK Den for de-escalation and one to one supervision. RN #1 assessed Resident #5 for physical injuries; however, CNA #9 reported that Resident #5 refused to come out of the safety of his/her room for the remainder of the night after the altercation. There was no evidence Social Services addressed the altercation and Resident #5's emotional response to the incident. The facility continued the same ineffective care plan interventions of "offer diversional activities" and "monitor/record" ; there was no reassessment, or supervision related to the Resident's pattern of escalating behaviors. According to interview with the DON, on 03/21/12 at 4:15 PM, it was the responsibility of the Social Services Director to review the BOP report, the nurse's notes, the daily sheet, and Behavior Management Log. Due to failure to effectively evaluate this data by the Social Services Director, there was no identification of Resident #5's escalating behavior or the need for increased supervision. Interview with the Social Services Director conducted on 03/21/12 at 6:25 PM revealed behavioral symptoms were addressed with re-education by speaking with the resident about inappropriate or aggressive behaviors. The re-education was considered successful with a behavior change of only 15 minutes, thus no changes were made to the care plans. Resident assessment for behavioral care planning was done quarterly for changes and as needed for incidents. The Social Services Director felt the needs of the residents were being met. Although evidence revealed Resident #1 and Resident #5 continued to have escalating physically abusive behaviors that resulted in harm for three residents.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to medically related Social Services to address resident behaviors that could lead to resident to resident abuse. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to medically related Social Services involvement with residents with behaviors that could lead to resident to resident abuse. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the Social Services Director has been provided training and updated tools to include a guide for care planning titled "The New Care Plan Answer Book for Activity, Psychosocial and Social Work Programs". The Social Services Director has worked in conjunction with the Minimum Data Set (MDS) Coordinator and DON to review and rewrite care plans approaches and interventions to address behaviors. A system has been established to monitor the Behavior Observation Program (BOP) sheets on a daily basis for the effectiveness of behavioral interventions and the need for care plan revision. The Social Services Director is monitored daily by the Quality Assurance Review team (Monday through Friday) and the Administrator (weekends and holidays) as issues and/or concerns are revealed. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview and record review, the facility failed to provide services for one residents (#3), in the selected sample of seven residents, related to the lack of, inadequate or incorrect implementation of the resident's written plan of care. The facility failed to ensure one resident (#3) was provided supervision and staff assistance with feeding and receive the appropriate food form per the physician's orders [REDACTED]. The facility was knowledgeable regarding Resident #3's need for therapeutic mechanically altered diet, per physician's orders [REDACTED]. On 01/22/12, the facility failed to provide total feeding assistance and supervision to Resident #3 after serving him/her a bologna sandwich which was not mechanically altered. The facility staff witnessed the resident choking, unable to breathe, having no air movement to the lungs and ashen in color. The facility staff had to perform the [MEDICATION NAME] Maneuver. The facility down-graded the resident's diet to pureed meat; however, on 03/15/12, the facility staff was observed serving Resident #3 meat that was not in the appropriate food form of pureed and failed to provide total feeding assistance supervision. The facility's failure to ensure staff provided necessary care and services and implemented the care plan as developed to prevent choking caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 01/22/12 and is ongoing. Prior to exit, the facility did not submit an Allegation of Compliance to remove Immediate Jeopardy. (Refer to F365) Findings include: 1. Administrator (a certified nutritionist) and the Director of Nursing (DON), on 03/16/12 at 4:00 PM, revealed during interview that mechanically altered diet meant the food was to be "put through a machine," no raw vegetables, very soft bread, crackers and toast was acceptable, and that "when put in the mouth would become soft" and total assistance meant "fed by staff." The Dietary Manager (DM), on 03/15/12 at 3:55 PM, revealed the facility process for checking therapeutic diet consistency started in the kitchen as a three layer check by the cook, the kitchen aide and the Dietary Manager. The final check is performed by the staff person serving the tray (usually a CNA) to verify that the food on the tray was correct before serving it to the resident. A record review revealed the facility admitted Resident #3 on 05/08/07 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#3 a "mechanical soft diet". A review of the quarterly MDS assessment, dated 01/01/12, revealed the facility assessed the resident to require extensive assistance of one person physical assistance for eating. A review of the plan of care, dated 01/01/12, revealed Resident #3 was to be "totally fed by staff." and the facility was to provide Resident #3 with mechanically altered diet, per diet orders. Nurses' notes, dated 01/22/12 at 6:05 PM, revealed documentation by Registered Nurse (RN) #1 to include "Notified by Certified Nurse Aide (CNA) that resident was choking. Ran down to room, resident ashen in color. Unable to breath, no air movement to lungs. [MEDICATION NAME] Maneuver done, coughed up large piece of bologna." Interview with the Dietary Manager, on 03/15/12 at 3:55 PM, revealed a sandwich was the substitute on 01/22/12, and someone must have provided a sandwich to Resident #3. An interview with CNA #1, on 03/16/12 at 2:30 PM, revealed, during the supper meal on 01/22/12, she had provided Resident #3 his/her supper tray and left the room to feed other residents. When she returned to the room, Resident #3 was choking on a piece of bologna he/she had fed to himself/herself. CNA #1 revealed the resident had one half of a bologna sandwich and the bologna had been a solid piece. An interview with RN #1, on 03/16/12 at 2:15 PM, revealed during the supper meal on 01/22/12 CNA #1 came to the nursing station and reported Resident #3 was choking. She ran to the resident's room and Resident #3 was not getting any air and she performed the [MEDICATION NAME] Maneuver. The resident coughed up a blob that had bread and a piece of bologna about the size of a fifty-cent piece. RN #1 did not recall if the resident was supposed to be fed by staff and stated the CNAs were to follow the care plan related to feeding. A review of the facility's investigation report, dated 01/22/12, revealed the facility identified Resident #3 did not receive the appropriate mechanically altered diet order; however, they did not identify that staff did not provide total feeding and supervision to Resident #3 during the noon meal. The facility modified the care plan to reflect "At risk for choking" and added the intervention, dated 01/22/12, "staff to monitor resident closely for choking." There was no change made to the care plan detailing the resident no longer needed to be totally fed by staff. On 03/15/12 at 12:00 PM, an observation of a meal service revealed Resident #3 was in his/her room with no staff present. The resident was holding onto a spoon that was in the food on the plate. The resident's diet card read "Mechanical Soft Pureed Meats." Resident #3's food tray contained a hot dog bun cut into five sections, with chili, which contained chunks of ground beef and chunks of hotdog. Further observation revealed the meat on the food tray was not the appropriate food form of pureed. An interview with CNA #3, on 03/16/12 at 11:55 AM, revealed, on 03/15/12, when delivering Resident #3's lunch tray "I set the tray down and left the room. Yesterday I thought (he/she) could feed (himself/herself). (He/she) gets started and we help (him/her) finish up." An interview with CNA #2, on 03/16/12 at 12:30 PM, revealed on 03/15/12, the food staff served Resident #3 had chunks of hot dogs and chunks of hamburger meat on it. She stated the meat "was not pureed." Thus the facility could provide no evidence that the staff followed the care plan to totally feed Resident #3 during meals, who the facility had identified as a choking risk and for staff to monitor closely. Furthermore, there was no evidence that the nursing staff was monitoring the therapeutic diet served to the resident to ensure it was the appropriate food form to prevent further potential for choking. An interview with the Director of Nursing (DON), on 03/21/12 at 4:15 PM, revealed the facility had not determined if the staff understood the function of the care plans.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to implementation of interventions related to resident to resident abuse and specialty diets. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to the implementation of interventions related to resident to resident abuse and specialty diets. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed the Minimum Data Set (MDS) Coordinator reviewed and revised the Behavior Observation Program (BOP) sheets and the nurse aide care plans for all residents on 03/29/12. The revisions included interventions specific to each resident with a sticker placed on the BOP sheet as a reminder of the suggested interventions. Further, training was completed on 03/29/12, for all nursing staff and new hires during orientation regarding appropriate documentation on the Behavior Management Log to indicate resident responses to interventions attempted. In an instance of unsuccessful attempts, the nursing staff are to notify the charge nurse for assessment of the need for 1:1 supervision. Resident #2 and Resident #3 were placed on one to one supervision for all meals and snacks. All resident dietary care plans were reviewed and revised by the Registered Dietitian (RD) or Certified Nutritionist (CN) on 03/29/12. A comparison between the physician's orders [REDACTED]. A daily review with updates as needed was performed by the Registered Dietitian and/or the Certified Nutritionist. Resident meal/tray observations were initiated on 03/21/12 for all resident diets at the point of tray origin for all meals. Supervised dining was initiated on 03/17/12 for all residents requiring assistance of feeding. An additional dining room was set up on 03/16/12 for all resident who required assistance with feeding. Those residents identified for high risk were supervised one to one with feeding. All dietary staff and staff members were educated on Modified Textured Diets on 03/28/12 and 03/29/12. A pre-test and post-test was administered. Modified texture diet trays are checked by a licensed staff member prior to serving to ensure the residents are receiving the appropriate diet. This will continue for 30 days and reports are communicated to the DON for review and then the Administrator by the DON. A report is then communicated to the Corporate Compliance Nurse daily by the Administrator. Any problems identified were corrected immediately. A system has been established for charge nurses to report, on a daily basis, any dietary care plan changes not made by the RD or CN to the DON who would then report the changes to the RD or CN for review. A daily report was made to the Corporate Compliance Nurse detailing dietary care plans and diet orders. Snacks are reviewed by the Certified Medication Aides (CMA's) and monitored by the CMAs with documentation provided to the DON daily. The DON provides communication to the Administrator daily. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure two residents (#2 and #3), in the selected sample of seven residents, received food in a form to meet their individual needs. The facility failed to follow their policy and procedure and the standard of practice for which the facility utilizes: Academy of Nutritional Dietetics Level 2 Nutrition Therapy for Dysphasia; Mechanically Altered Foods. The facility was knowledgeable regarding Resident #3's [DIAGNOSES REDACTED]. On 01/22/12, the facility staff served a bologna sandwich which was not in the food form of mechanically soft. The facility staff witnessed the resident choking, unable to breathe, having no air movement to the lungs and ashen in color. The facility staff had to perform the [MEDICATION NAME] Maneuver. The facility down-graded the resident's diet to pureed meat; however, on 03/15/12, the facility staff was observed serving Resident #3 meat that was not in the food form of pureed consistency. Additionally, the facility was knowledgeable of Resident #2's physician order [REDACTED].#2 meat that was not in the food form of a mechanical soft texture. The facility staff witnessed the resident choking, face turning red and had to perform the [MEDICATION NAME] Maneuver. While the facility had identified the issue of Resident #3 receiving food during meal service that was not in the appropriate food form per the resident ' s individual needs and physician's diet order and had initiated in-services with nursing and dietary staff in January and immediately following the choking incident in February with Resident #2, observation of the meal service on 03/15/12 revealed the interventions the facility had implemented were not effective as the facility continued to serve Resident #3 food in a form that was not the consistency required for the resident and which did not follow the diet order as required for the resident's safety to prevent choking. Interview with CNA #2 revealed the noon meal usually had pureed meats that had chunks of meat, where you had to pick the chunks out. The facility failed to identify continued problems with their system for monitoring food form for appropriate consistency even after two residents choked and had to have the facility staff perform the [MEDICATION NAME] Maneuver. Prior to exit, the facility did not submit an Allegation of Compliance for the removal of Immediate Jeopardy. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 03/21/12 and determined to exist on 01/22/12. The Immediate Jeopardy is on-going. Findings include: Interview with the Registered Dietitian, on 03/21/12 at 3:40 PM, revealed the facility cites the Academy of Nutritional Dietetics as their reference for standards of practice and policy and procedure. A review of Level 2 Nutrition Therapy for Dysphasia; Mechanically Altered Foods, undated, included "The purpose of mechanically altering foods is to provide foods that can be successfully and safely swallowed. This diet consists of foods that are mechanically altered by blending, chopping, grinding or mashing so that they are easy to chew and swallow. Foods in large chunks or foods that are too hard to be chewed thoroughly should be avoided." The Foods not Recommended section included "hotdogs" and "sandwiches." An interview with the Administrator (a certified nutritionist), and the Director of Nursing (DON), on 03/16/12 at 4:00 PM, revealed mechanically altered diet meant the food was to be "put through a machine," no raw vegetables, very soft bread, crackers and toast was acceptable, and that "when put in the mouth would become soft." An interview with the Dietary Manager (DM), on 03/15/12 at 3:55 PM, revealed the cook was to check the diet for the right consistency when he plated the food and the kitchen aide was supposed to look at it and verify it was correct. The Dietary Manager was to observe and document that trays were leaving the kitchen with the appropriate diet. The staff person serving the tray (usually a CNA) was supposed to verify that the food on the tray was correct before serving it to the resident. 1. A record review revealed the facility admitted Resident #3 on 05/08/07 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Annual Minimum Data Set Assessment, dated 01/01/12, revealed the facility assessed the resident as having a mechanically altered diet requiring a change in texture of food. A review of the plan of care, revised 10/04/11, revealed the facility was to provide Resident #3 with mechanically altered diet, per diet orders. Review of the Nursing Assistant Care Plan, initiated on 01/2012, revealed the resident was to receive mechanical soft diet. A review of the nurse's notes, dated 01/22/12 at 6:05 PM, revealed documentation by Registered Nurse (RN) #1 to include "Notified by Certified Nurse Aide (CNA) that resident was choking. Ran down to room, resident ashen in color. Unable to breath, no air movement to lungs. [MEDICATION NAME] Maneuver done, coughed up large piece of bologna." An interview with RN #1, on 03/16/12 at 2:15 PM, revealed during the supper meal on 01/22/12, Certified Nurse Aide (CNA) #1 came to the nursing station and reported Resident #3 was choking. She ran to the resident's room and Resident #3 was not getting any air and she performed the [MEDICATION NAME] Maneuver. The resident coughed up a blob that had bread and a piece of bologna about the size of a fifty-cent piece. An interview with CNA #1, on 03/16/12 at 2:30 PM, revealed during the supper meal on 01/22/12 she had provided Resident #3 his/her supper tray and left the room to feed other residents. When she returned to the room, Resident #3 was choking on a piece of bologna he/she had fed to himself/herself. CNA #1 revealed the resident had one half of a bologna sandwich and the bologna had been a solid piece. A review of the facility's investigation report, dated 01/22/12, revealed the incident as "choking on food" and the action/intervention taken to prevent/reduce happening again as "close observation while eating" and "dietary to spread meat on bread." The resident's care plan for "At risk for choking" revealed an intervention, dated 01/22/12, which stated "staff to monitor resident closely for choking." The Dietary Manager (DM), on 03/15/12 at 3:55 PM, revealed a sandwich was the substitute, on 01/22/12, and someone must have provided a sandwich to Resident #3. Further interview with the DM, on 03/15/12, and the Administrator, on 03/20/12 at 10:50 AM, revealed the Administrator, a Nutritionist, followed the facility ' s policy and down-graded Resident #3's diet to pureed meat on 02/26/12. An observation of a meal service, on 03/15/12 at 12:00 PM, revealed Resident #3 was in his/her room with no staff present. The resident was holding onto a spoon that was in the food on the plate. The resident's diet card detailed "Mechanical Soft Pureed Meats." Resident #3's food tray contained a hot dog bun cut into five sections, with chili, which contained chunks of ground beef and chunks of hotdog. Further observation revealed the meat on the food tray was not pureed. An interview with CNA #3, on 03/16/12 at 11:55 AM, revealed, on 03/15/12, when delivering Resident #3's lunch tray "I set the tray down and left the room..." An interview with CNA #2, on 03/16/12 at 12:30 PM, revealed on 03/15/12 Resident #3's meal tray had chunks of hot dogs and chunks of hamburger meat on it. She stated the noon meal usually contained pureed meat which contained chunks and she "just picked the chunks out." She stated the meat in Resident #3's lunch meal, on 03/15/12, "was not pureed." Resident #3 ate about 50% of that meal. Continued interview with the DM, on 03/15/12, revealed Resident #3 was supposed to have pureed meat, and the ground beef and chunks of hot dog were not pureed. She stated "The cook made a mistake." She gave no explanation as to how Resident #3 received meat on his/her lunch tray, which was not pureed even though the DM had stated that the Cook, Kitchen Aide, the Dietary Manager and the staff serving the tray were all to check to ensure appropriate food consistency was being served to each individual resident. 2. A record review revealed the facility admitted Resident #2 on 04/10/08 with [DIAGNOSES REDACTED]. A physician's diet order for mechanical soft texture was initiated on 09/20/11. Review of the care plan, revised 12/13/11, revealed the resident had a therapeutic mechanically altered diet and staff was to provide diet per orders. A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/19/11, revealed the facility assessed the resident as having a mechanically altered diet requiring a change in texture of food. A review of the nurses' notes, dated 02/26/12 at 12:00 PM, and interview with CNA #11, on 03/16/12 at 12:40 PM, revealed "Resident up to wheel chair eating lunch. Resident noted as unable to breath and face very red. [MEDICATION NAME] Maneuver performed. Food expelled from throat and removal from mouth. Excessive amount of food noted in mouth. Pulled meat noted in resident's mouth and on tray." Further interview with CNA #11 revealed she did not check the tray to ensure that Resident #2's meal was served at the appropriate consistency. A review of the facility's investigation report, dated 02/26/12 at 12:00 PM, revealed the resident was noted to be unable to breathe, his/her face was red and the [MEDICATION NAME] Maneuver was performed. An excessive amount of pulled meat was found in the resident's mouth. The meat in the resident's mouth and on the resident's tray was described as pulled meat. The Registered Dietician, on 03/15/12 at 4:00 PM, revealed the incident happened on a Sunday and she was made aware that the facility thought the resident had received pulled meat instead of mechanically altered. While the facility had implemented in-service training to dietary staff on 02/27/12 and 02/28/12, and in-serviced nursing staff on 02/29/12 to make certain that any modified textures served to residents are the appropriate texture, observation of the noon meal service on 03/15/12 and interview with CNA #2 and the DM, as previously detailed, revealed the facility continued to serve meals that were not in the appropriate food form to meet the resident's individual need and diet order. An interview with CNA #2, on 03/16/12, revealed the noon meal usually contained pureed meat which contained chunks and she "just picked the chunks out." Continued interview with the DM revealed the cook made a mistake on 03/15/12, she was unable to explain how the facility was effectively monitoring the therapeutic diets to ensure that the food was served in the appropriate form and consistency with the resident's diet order and to prevent choking. Prior to exit, the facility had not submitted an allegation of compliance to remove immediate jeopardy.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 03/22/12, had been removed related to ensuring residents received food in a form that met their individual needs. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and had not had an opportunity to develop and implement a Plan of Correction (POC), related to residents receiving food in a form that meets their individual needs. The findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 03/21/12, revealed all dietary staff were trained on 03/29/12 regarding Modified Texture diets with a pre-test and post-test completed. Additionally, all facility staff were inserviced by the Registered Dietitian, on 03/29/12, on texture modified diets to include the requirements of texture modification and recognition of texture modification. Monitoring of texture modification food trays begins with food preparation and tray checks in the kitchen and is provided currently by the Registered Dietitian (RD) or Certified Nutritionist (CN). With delivery of the trays to the dining areas, the trays are checked by a licensed staff prior to presentation to the residents. Any problems are corrected immediately and reported to the RD, the Administrator, and the Corporate Compliance Nurse. The daily monitoring of trays is scheduled to continue for 30 days by licensed staff in the kitchen and at the point of service. Reports, beginning with the licensed staff, flow to the DON for review, then to the Administrator and finally to the Corporate Compliance Nurse. Currently, the food preparation is being monitored by an experienced Assistant Dietary Manager from a sister facility and the Head Cook in that the Dietary Manager was terminated on 03/29/12. The newly hired dietary staff are being trained by the Assistant Dietary Manager and/or the RD or CN. Interview with the Administrator, on 04/10/12 at 2:45 PM, revealed the facility was continuing to monitor and discuss concerns identified during rounds so they could be addressed with the QA committee and deficient practice could be removed. She stated the facility had not had an opportunity to develop and implement a Plan of Correction (PoC) as the facility had not received the Statement of Deficiencies (SoD).

Based on interview, record review, and review of the facility's policy/ procedure, it was determined the facility failed to ensure all alleged violations, including injuries, were reported in accordance with State law through established procedures. The facility failed to provide evidence that an alleged violation was thoroughly investigated to prevent further potential abuse for one resident, (#7), in the selected sample of seven residents. On 02/08/12, the facility received a verbal allegation from a Non-Facility Provider that Resident #1 hit Resident #7, his/her roommate, on the left side of the head with a Bible, on an unknown date. The facility failed to conduct an investigation of the allegation, report the allegation to the appropriate state agencies and failed to protect residents of the facility from further potential abuse. Due to this failure, the facility allowed Resident #1 continued access to all residents of the facility resulting in continued escalating behaviors and incidents towards others residents. On 02/11/12, Resident #1 physically attacked a staff member throwing him/her on the bed and kicking his/her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #5, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. Observation on 03/16/12 revealed Resident #1 continued to have full access of the facility without staff supervision to ensure protection of other residents. Prior to exit, the facility had not submitted an Allegation of Compliance to remove Immediate Jeopardy. This failure to follow their abuse policy by reporting, investigating and implementing protective and preventive measures caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 02/08/12 and is ongoing. (Refer to F223, F226, F250, and F323) Findings include: A review of the facility's policy/ procedure, "Resident Abuse, Neglect, and Exploitation," dated 02/07/12, revealed it was the resident's right to be free from mistreatment and the facility's goal was to protect the health and welfare of each resident and assure each resident was free from verbal, sexual, physical and mental abuse. Employees were directed to report immediately to the supervisor and the Administrator or designee would take prompt action to protect the alleged victim of the abusive act. A statement from a resident or visitor would have been considered as strongly as that from an employee and would have been given the same considerations. A record review revealed the facility admitted Resident #7 on 04/01/11 with [DIAGNOSES REDACTED]. He/she functioned independently and required limited assistance with mobility, ambulation, toileting, and dressing. An interview with Resident #7, on 03/20/12 at 10:45 AM, revealed he/she recalled being roommates with Resident #1. Resident #7 expressed he/she had to get out of that room and stated he/she was hit by Resident #1 on the left side of the head with a Bible. An interview with the Administrator, on 03/16/12 at 4:15 PM, revealed no investigation worksheet was completed and she had no knowledge of an incident related to Resident #1 and Resident #7 being roommates. In regard to Resident #1, the staff were aware to observe the resident and to deal with behaviors daily. Resident #1 was described as an "intimidator" and "difficult." (Refer to F223) An interview with Certified Nurse Aide (CNA) #9, on 03/16/12 at 12:30 PM, revealed Resident #7 was roommates with Resident #1. It was reported Resident #7 was afraid to go to bed and Resident #1 was found several times at the bedside, standing over Resident #7 during the night. An interview with Registered Nurse (RN) #1, on 03/16/12 at 2:25 PM, revealed Resident #7 requested a new room and stated he/she did not like Resident #1. The facility provided no evidence the report was passed on to Administration or Social Services. An interview with Licensed Practical Nurse (LPN) #4, on 03/19/12 at 4:05 PM, revealed a verbal altercation between Resident #1 and Resident #7 occurred on 01/20/12. A review of the nurse's notes, dated 01/20/12 at 3:00 AM, and signed by LPN #4, revealed Resident #1 was found cussing at Resident #7, who was asleep. At 4:00 AM, on the same date, Resident #1 continued to cuss and threaten Resident #7, who was not in the room. An interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed Resident #7 was granted a room change, on 02/08/12, after a complaint that heated words were passed between the roommates (Resident #1 and Resident #7), and Resident #7 reported "just tired of that (Resident #1). The request was reported to a non-facility provider who worked with Resident #7 on a weekly basis. There was no investigation completed related to the discovery of the reason for the room change request. Interview, on 03/20/12 at 12:05 PM, with the Non-Facility Provider who worked with Resident #7 on a weekly basis, revealed Resident #7 reported he/she wanted a room change because of being hit with a Bible by Resident #1. The Non-Facility Provider reported the incident to the facility office staff, on their way to a meeting. The facility staff responded they were not aware of any incidents. The Non-Facility Provider revealed Resident #7 voiced he/she was not happy and requested a room change. The facility staff advised that the information would be discussed at the care plan meeting the following day. The regular visit by the Non-Facility Provider, one week later, found Resident #7 in a new room and there were currently no further complaints from Resident #7. An interview with Facility Staff #1, on 03/20/12 at 12:15 PM, revealed the non-facility provider revealed Resident #7 was not happy with his/her roommate and needed a room change. There was no mention that Resident #1 struck Resident #7. The information was reported during the morning meeting. An interview with the Director of Nursing (DON), on 03/21/12 at 4:15 PM, revealed the incident report process was to be completed by the licensed staff on duty. Initiation of the investigation included the basic cause and what caused the problem. The information should be sent to the DON and discussed in the morning meeting. At the time of an incident, the licensed staff was to obtain statements from all the residents and staff in the area; however, not the entire building. During the morning meeting, the discussion determined what interventions were effective. At that time the interventions may be changed, added to, or left the same. Further interview revealed this process was not conducted for Resident #7 related to altercations with Resident #1.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure four residents (#4, #5, #6, and #7), in the selected sample of seven residents, were free from abuse by Resident #1. The facility failed to follow the abuse policy/procedure. The facility failed to identify the Resident #1's personal history, diagnoses, and the facility's assessment of Resident #1, as factors that could render him/her to be a risk for abuse toward other residents. Staff interviews revealed they knew they should not turn their back to Resident #1 due to his/her history of violence toward other residents and staff. Resident #1's attending psychiatrist stated Resident #1 was known to demonstrate classical Intermittent [MEDICAL CONDITION] and describing these behaviors as unpredictable for the intensity of the violence and that the actions are not planned, but willful, as the anger is demonstrated in "all-out" aggression. On 01/20/12, Resident #1 made threats of harm toward Resident #7. On 02/08/12, the facility received an allegation of physical abuse alleging Resident #1 hit Resident #7 on the head with a Bible. On 02/11/12, Resident #1 physically attacked a staff member throwing him/her on the bed and kicking his/her head into the footboard of the bed, then threw his/her walker at another staff member. On 02/14/12, Resident #1 had a verbal confrontation with Resident #6. On 02/19/12, staff found Resident #1 had "pinned" Resident #4 to the wall in the hallway, which was not witnessed. After staff removed Resident #1 from Resident #5, Resident #1 immediately turned and grabbed Resident #5, who has a bilateral, hip level amputation, by the clothing and attempted to drag the resident from the wheelchair. Resident #4 sustained substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety expressing fear to the staff stating "I need a gun." Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident per facility staff. The facility could provide no evidence detailing that they identified Resident #1's behaviors as a risk for potential abuse, initiated an investigation or implemented interventions to protect other residents from further potential abuse. Prior to exit, the facility did not submit an Allegation of Compliance for the removal of Immediate Jeopardy. This facility's failure to follow their Abuse policy and procedure, identify escalating behaviors that potentially could render a resident at risk for abusing others, investigate incidents and allegations of abuse, prevented the facility from implementing effective interventions to prevent abuse by Resident #1 for four residents (#7, #4, #5, #6) which caused harm for two residents and is likely to cause serious injury, harm, impairment, or death to a resident. It was determined Immediate Jeopardy and Substandard Quality of Care was identified on 03/21/12 and determined to exist on 02/08/12 and is ongoing. (Refer to F225, F226, F280, F282, F323, and F250) Findings include: A review of the facility's policy/ procedure, "Resident Abuse, Neglect and Exploitation," dated 02/07/12, revealed the facility's goal was "to have a process in place to protect the health and welfare of each resident and to assure each resident was free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin". The policy/procedure began the process with screening of potential employees and followed by training of employees. During orientation of a new employee, student, and/or volunteer, the Abuse Policy would be discussed with a signature acknowledging understanding. This in-service education included appropriate interventions to deal with aggressive and/or catastrophic reactions of a resident; the procedure for reporting an allegation; recognition of burnout, frustration, and stress; the specifics of abuse, neglect, and misappropriation of resident property; methods of identification of suspicious injuries and how to investigate; and the recognition of patterns and trends that may be suspicious of abuse. Prevention measures would include providing information and encouragement for reporting incidents, use of the Continuous Quality Improvement Process to identify and correct situations at high risk for abuse occurrence, areas of the building and grounds that provided increased risk for abuse, staff training and documentation tools used for abuse identification and reporting, identification of residents whose personal histories and/or [DIAGNOSES REDACTED]. The section titled Identification distinguishes abuse by a staff member from resident to resident abuse. the Abuse by a staff member section identified steps to follow as reporting immediately to the employee's immediate supervisor with immediate suspension until the investigation resolved the issue and reporting of the incident to the appropriate entities. In the occasion of resident to resident abuse, the residents involved in allegations of resident-to-resident abuse should be separated from each other to first assure resident's safety and protection with notifications made to the appropriate entities. An evaluation of the alleged perpetrator would be completed to determine a potential cause related to a medical need. The alleged victim would be evaluated and treated as needed. Reporting the alleged abuse would include documentation of injuries, investigation documentation, and reports to the appropriate authoritative entities. A record review revealed the facility admitted Resident #1 on 04/07/06 with [DIAGNOSES REDACTED]. Interview with Resident #1's attending psychiatrist, on 03/21/12 at 12:08 PM, revealed Resident #1 was known to demonstrate classical behaviors related to Intermittent [MEDICAL CONDITION] and this disorder was known to be genetic. The psychiatrist further reported Intermittent [MEDICAL CONDITION] as a frequently missed [DIAGNOSES REDACTED]. The psychiatrist described these behaviors as unpredictable for the intensity of the violence and that the actions are not planned, but willful, as the anger is demonstrated in "all-out" aggression. The psychiatrist further described Resident #1 as being "pretty sick" with the combined [DIAGNOSES REDACTED]. A review of the comprehensive care plan, developed and initiated on 11/23/11, revealed a plan to address Resident #1's agitated behavior of banging his/her walker on the floor, throwing objects, hitting staff and threatening others secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. A review of care plan interventions revealed staff were to "offer diversional activities of enjoyment," and "monitor closely for signs of increased frustration and/or anxiety". An interview with RN #1, on 03/16/12 at 2:25 PM, revealed uncertainty about what "set off" Resident #1, and stated sometimes it took nothing to set the resident off. The staff monitor the resident closely trying to keep him/her away from females. An interview with Licensed Practical Nurse (LPN) #1, on 03/18/12 at 7:03 PM, revealed Resident #1 was known to be aggressive with staff and other residents. When fixated on something, redirection was not possible. "Fussing and cussing" were considered normal behaviors for Resident #1, and as long as the behaviors did not become physical, the behaviors were allowed to continue. An interview with CNA #9, on 03/16/12 at 12:30 PM, revealed employees knew not to turn their backs to Resident #1. The incident, on 02/19/12, was not the first time the resident was violent with other residents and staff. An interview with LPN #4, on 03/19/12 at 4:05 PM, revealed, on 01/20/12, Resident #1 had a verbal altercation with Resident #7, and Resident #1 made verbal threats toward Resident #7. At that particular time, Resident #1 apologized after the incident was over. The apology was believed to be sincere and according to his/her tone of voice, his/her facial expressions and a change in behavior, he/she believed the resident was aware of his/her inappropriate behaviors. However, there was no evidence provided by the facility that interventions were implemented to address Resident #1's threat of violence toward another resident, nor was there evidence the facility took action to provide protection to the residents of the facility. A review of the care plan, after the incident on 01/20/12, revealed the facility made no changes to address Resident #1's threatening behavior nor made any revisions to the care plan. An interview with Resident #7, on 03/20/12 at 10:45 AM, revealed Resident #1 had struck him/her on the head with a Bible sometime prior to his/her room transfer on 02/08/12. Resident #7 stated he/she had requested a room transfer related to the threatening behaviors exhibited toward him/her. An interview with RN #1, on 03/16/12 at 2:25 PM, revealed Resident #7 had expressed a desire to change rooms and he/she did not like his/her roommate. An interview with CNA #9, on 03/16/12 at 12:30 PM, revealed Resident #1 was often found standing over Resident #7 while he/she slept during the time they were roommates. An interview with the Administrator, on 03/17/12 at 9:30 AM, revealed Resident #1 was described as an "intimidator" and "difficult." Staff were aware to be observant of Resident #1 and deal with behaviors daily. Interview with the Non-Facility Provider, on 03/20/12 at 12:05 PM, revealed that Resident #7 informed her on two occasions of being "tired of that (resident)." She reported to the facility that Resident #1 and Resident #7 had "heated words," and an inability to get along with each other. She further revealed that Resident #7 told her that Resident #1 had struck him/her on the head with a Bible. She made this verbal report of physical abuse to Facility Staff #1. An interview with Facility Staff #1, on 03/20/12 at 12:15 PM, revealed the conversation with the Non-Facility Provider reported that Resident #7 voiced he/she was unhappy with his/her roommate and desired a room change. The information was presented at the morning meeting. An interview with the Social Services Director, on 03/20/12 at 9:30 AM, revealed Resident #7 requested a room change and was moved, on 02/08/12, as a result of the information presented in the morning meeting. While facility staff were made aware of the allegation of abuse, there was no evidence the facility initiated an investigation or provided protection to the other residents of the facility from the alleged perpetrator (Resident #1). Further interview with the Social Services Director, as well as a review of the social services e-mail notification to the county representative for the Department of Aging and Independent Living (DAIL), revealed the facility completed a room change for Resident #7 without an investigation into the reason behind the requested room change. An interview with CNA #5, on 03/20/12 at 5:19 PM, and CNA #6, on 03/20/12 at 2:05 PM, revealed, on 02/11/12, while assisting Resident #1 for bed, the resident grabbed CNA #5 with his/her legs. Resident #1 "flipped" CNA #5 onto the bed and proceeded to forcefully kick CNA #5's head into the foot board of the bed. Resident #1 proceeded to throw a walker into the wall next to the CNA #6. An interview with LPN #4, on 03/20/12 at 3:20 PM, revealed Resident #1 was diverted by LPN #4's one-on-one attention after this incident, on 02/11/12. It took approximately 20 minutes before calmness was achieved. The facility could provide no documented evidence of this incident; however, interview revealed the information was passed on in shift report. A review of the care plan, after this incident, revealed the facility made no changes to address the resident's physically aggressive behaviors nor revisions to the care plan in an effort to manage the behaviors, and/or ensure protection of other residents in the facility. Furthermore, there was no evidence the facility attempted to investigate the incident or identify Resident #1 was at risk for abusing others. A review of an investigation worksheet, dated 02/14/12, revealed Resident #1 had a verbal confrontation with Resident #6 which necessitated a room change for Resident #6. While the facility initiated a room change for Resident #6, a review of the care plan after this incident, revealed the facility made no changes to address the resident's verbally aggressive behaviors, nor made revisions to the interventions in an effort to manage the behaviors and/or ensure protection of other residents in the facility. There was no evidence the facility identified Resident #1's behaviors as abusive. A review of the nurse's notes and the investigation worksheet, dated 02/19/12, revealed facility staff heard a commotion and found that Resident #1 had "pinned" Resident #4 with his/her face to the hallway wall, and Resident #1 had restrained both of Resident #4's wrists with his/her hands. The facility staff separated Resident #1 and Resident #4, at which time Resident #1 immediately turned and grabbed Resident #5's clothing. Resident #5 was wheelchair bound, having had a bilateral hip level amputation. Resident #1 attempted to pull Resident #5 from his/her wheelchair. The facility staff escorted Resident #1 to the facility's UK Den at which time the facility notified the police. An interview with the police, on 03/21/12 at 11:00 PM, revealed the incident was considered a fourth (4th) degree assault. Further record review revealed the facility assessed Resident #4 and found the resident had substantial bruising on his/her hands bilaterally, along with demonstrating fear and anxiety. A review of the nurse's notes revealed "Resident afraid. Told me (he/she) was afraid of 'the (resident)' and stated (he/she) needed a gun." Additionally, an interview with CNA #9 revealed, on 03/16/12, that Resident #5 demonstrated anxiety and refused to leave the safety of his/her room after the incident. A record review revealed Resident #1's care plan, dated 02/19/12, revealed the short term goal listed was for the resident(s) to be redirected from the situation and placed in a safe environment. The approaches listed for the staff to implement included "remove resident(s) from area/situation, notify Charge Nurse immediately; assess resident(s) for any harm; provide safe environment; close observation of resident, provide 1:1 as indicated; notify the physician and the responsible party of the incident." The added approach was "1:1 supervision." Under the comment section was information related to Resident #1's transfer to the psychiatric hospital on [DATE]. The facility initiated one-to-one supervision after the incident and transferred Resident #1 to a psychiatric hospital on [DATE]. A review of the psychiatric hospital discharge summary, dated 03/05/12, revealed Resident #1 demonstrated, on admission to the hospital, an episode [MEDICAL CONDITION] by mood lability, grandiosity, delusions, euphoria, sexual preoccupation, and pressured speech. At the time of discharge, the resident was no longer exhibiting agitation or aggression. The facility readmitted Resident #1 on 03/05/12. However, the facility could provide no evidence that they had identified Resident #1's physically aggressive behaviors as a risk for abusing other residents upon his/her re-admission to the facility. A record review revealed the facility provided no evidence that they re-assessed Resident #1 to determine the need for supervision to protect other residents from further potential abuse, despite staff knowledge of recent physical aggression toward other residents. A review of the care plan revealed the facility had not put any specific interventions into place related to supervision, upon the resident's return to the facility. Observation, on 03/16/12 at 10:30 AM, revealed Resident #1 was standing outside Resident #4's room. There was no staff observed in the hallway to provide supervision for Resident #1. An observation, on 03/16/12 at 3:23 PM, revealed Resident #1 was sitting on the side of his/her bed. The resident stated, "I'm not here just for love making," and invited the surveyor to come further into the room. Resident #4 came to the doorway of Resident #1's room. The surveyor observed Resident #1's body immediately stiffen, as he/she quickly moved to the edge of the mattress, pointed his/her index finger at Resident #4 and stated "This is a (man's/woman's) room, you (surveyor) can come in, but (Resident #4) can't be here." This surveyor, who was standing in the hallway, observed no facility staff present to provide supervision, behavior management, or redirection to protect Resident #4 from further assault and/or abuse. It was observed that Resident #1 was able to freely ambulate throughout the entire facility without supervision being provided by the facility. An interview with the Administrator, on 03/15/12 at 2:00 PM, revealed her knowledge of the facility's policy/ procedure on "Resident Abuse, Neglect and Exploitation," dated 02/07/12, included staff were to report incidents immediately after ensuring resident safety. Any staff to resident alleged abuse or neglect would result in immediate suspension of the employee until the investigation was complete. Resident to resident altercations would involve separation of the residents with appropriate notification to the Office of Inspector General and other required agencies. She expected the staff to follow the facility's policy/procedure for abuse and neglect. A Nurse Aide registry and criminal background check were completed prior to hiring staff. Abuse inservices were completed annually, or anytime there was an incident.