Every finding on record at Diversicare of Foley

Based on observations, interviews, record reviews, and facility guidelines, the facility failed to implement the facility's guidelines for Elopement. This occurred when Resident #98 was assessed as being at risk of elopement and no individualized plan was established and no interventions were developed to mitigate the risk until after Resident #98 exited the facility without staff's knowledge on 02/06/2023. In addition, the facility also failed to ensure Resident #320, a resident assessed by the facility as an elopement risk, was wearing a WanderGuard on 06/16/2023 as ordered. Further, the facility failed to ensure the facility's staff were checking the placement of Resident #320's WanderGuard every shift, in accordance with the plan developed by the facility following Resident #98's elopement. On 02/06/2023, Resident #98 left the facility without staff's knowledge. A local police officer returned Resident #98 to the facility at 3:45 PM. The officer reported that he/she found the resident approximately two blocks from the facility. In addition, the facility failed to thoroughly investigate the conditions surrounding Resident #98's elopement, as no statements were obtained from the police officer, family members that were visiting at the time of the elopement, and staff that worked the 3:00 PM to 11:00 PM shift. This deficient practice affected Resident #98 and Resident #320, two of three residents sampled for elopement. On 02/06/2023, ten of 31 residents residing on the secured unit were assessed by the facility as at risk for elopement. On 06/16/2023, 15 of 32 residents residing on the secured unit were identified as at risk for elopement. On 06/16/2023 at 9:25 PM, the Administrator, Director of Clinical Operations, Business Office Manager (BOM), and the Minimum Data Set Coordinator (MDSC) were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F689-Free of Accident Hazards/Supervision/Devices. On 06/16/2023 at 9:30 PM the Administrator, Director of Clinical Operations, BOM, and MDSC were provided a copy of the immediate jeopardy template. The immediate jeopardy began on 02/06/2023 and continued until 06/19/2023, when the facility implemented corrective actions to remove the immediacy and prevent further recurrences. Findings included: A review of the facility's Clinical Care System Guidelines on Elopement, dated April 2017, revealed, Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process On Admission Newly admitted or readmitted residents are assessed for elopement risk If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk When the nurse identifies the intervention it is documented on the care plan and on the caregiver guide . After admission when a newly identified elopement risk is identified The Risk of Elopement evaluation is completed to determine interventions An individualized plan is established and implemented to mitigate that risk The plan is documented on the care plan and caregiver's guide . If a bracelet alarm is chosen as an intervention there is a plan for monitoring of placement/function . 1. A review of Resident #98's Admission Record indicated the facility admitted the resident on 01/27/2023 with diagnoses that included Dementia with other Behavioral Disturbance and Adjustment Disorder with Anxiety. A review of a Clinical Health Status Evaluation, dated 01/27/2023 and completed by the MDSC, indicated Resident #98 was independent with bed mobility, transfers, and walking. The evaluation also indicated the resident was alert, confused, had memory impairment, and was oriented to person but not time or place. A review of the section titled Elopement revealed Resident #98 was physically able to leave the building, was cognitively impaired with impaired decision-making skills, made repetitive statements about going home, and had a history of wandering. The evaluation indicated that if the resident had a history of wandering, staff were to implement care plan. The evaluation further indicated that based on the assessment, Resident #98 was at risk of elopement. At the bottom of the form, the writer was directed to develop a care plan and discuss the risk of elopement with the interdisciplinary team (IDT). Under the narrative portion of the evaluation, the form indicated Resident #98 was to reside on the locked memory care unit. A review of Resident #98's Baseline Care Plan, signed by the MDSC and effective on 01/27/2023, revealed the section titled Elopement was not completed, and did not identify Resident #98's elopement risk or include any interventions addressing their elopement risk. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2023, indicated Resident #98 had a Brief Interview for Mental Status (BIMS) score of three of 15, indicating the resident had severe cognitive impairment. The MDS also indicated the resident wandered one to three days during the assessment period. A review of Resident #98's comprehensive care plans, first initiated on 01/30/2023, revealed no care plan had been developed for Resident #98's risk of elopement until 02/06/2023, after Resident #98's elopement from the facility. A review of Resident #98's Progress Notes revealed the following: - a Daily Skilled Nurses Note, dated 01/30/2023 at 4:21 PM, that indicated Resident #98 wandered the hall and rooms, and was asking how to get out of the unit. - a Daily Skilled Nurses Note, dated 01/31/2023 at 10:52 AM, that indicated Resident #98 often asked how to get out of the unit. - a Social Services note, dated 02/04/2023 at 11:17 AM, that indicated Resident #98 had previously resided in another facility and had frequent behaviors of wandering in and out of other resident's rooms. The note indicated the previous facility had recommended Resident #98's family place the resident in a secured memory care unit. The note also indicated that while Resident #98 said he/she were ready to leave, they had not demonstrated any exit-seeking behaviors so far. - a Daily Skilled Nurses Note, dated 02/04/2023 at 9:59 PM, that indicated Resident #98 had exit-seeking behaviors. The note did not describe what type of exit-seeking behaviors were exhibited by Resident #98. - a General Note, dated 02/06/2023 at 5:30 PM, that indicated a local police officer returned Resident #98 to the facility at 3:45 PM from an elopement where the resident had walked out of the facility with visiting family members. The police officer reported to the facility the resident had ambulated about two blocks from the facility. The note indicated that a WanderGuard was placed on Resident #98's left ankle. A review of the facility's Investigation Template, dated 02/13/2023, revealed, . it is the belief of this facility that [Resident #98] most likely pushed on the door after it was opened using the keypad. [Resident #98] was fully dressed with [his/her personal bag] on [his/her] shoulder when [he/she] exited so it is also the belief of this facility that someone let [him/her] out the front door thinking that [he/she] was a visitor . The facility's investigation included review of Resident #98's medical record, a body audit on Resident #98, and statements from a floor nurse, Certified Nursing Assistant (CNA) #15, and CNA #16. There were no other interviews or statements, including from the police officer that returned Resident #98 to the facility, family members visiting the facility around the time of the elopement, or staff working the 3:00 PM to 11:00 PM shift. On 06/13/2023 at 9:39 AM, Resident #98 was observed sitting by the exit door of the secured dementia unit with their personal bag in hand. A staff member entered the secured unit, and Resident #98 was observed attempting to leave as the staff member entered the unit. Certified Nursing Assistant (CNA) #15 was interviewed by telephone on 06/15/2023 at 10:00 AM. CNA #15 stated she had worked on the day shift the day Resident #98 eloped. CNA #15 stated that around 2:00 PM on 02/06/2023, Resident #98 was sitting at a table in the dining room eating and drinking snacks. At about 2:30 PM, a resident and that resident's family member were in the dining room, and Resident #98 got up to visit with that resident. At 3:00 PM, the evening shift began to arrive. CNA #15 stated the visiting family member left before evening shift arrived and added that the last time she saw the resident was at 3:00 PM when she was leaving at the end of her shift. The CNA stated no one knew for sure when Resident #98 left the secured unit. CNA #15 stated she received a call about 30 minutes after she left the building on 02/06/2023 asking her about Resident #98 and when she had last seen the resident. CNA #15 stated that prior to Resident #98 leaving the secured unit, the resident had not worn a WanderGuard and could have been mistaken for a visitor. The CNA also stated that prior to Resident #98's elopement, the resident had exit-seeking behavior and would try to get out of the door and say they had to go to Mobile. CNA #15 indicated staff tried to divert the resident by offering snacks and music, and that worked for a while, but when the diversion wore off, Resident #98 continued to try to exit the secured unit. CNA #15 said she did not report RI #98's behavior to charge nurse or management staff because she thought everyone already knew. On 06/15/2023 at 10:15 AM, a telephone interview was held with CNA #16. CNA #16 stated she had worked on the secured unit the day Resident #98 eloped. CNA #16 stated that even prior to the elopement, Resident #98 would walk up and down the hall asking to leave and would go to the exit door and stand. CNA #16 stated that on 02/06/2023, she saw Resident #98 between 2:30 PM to 2:40 PM in the dining room with another resident. Both residents left the dining room and began walking up and down the hall. CNA #16 stated she left the secured unit at 3:00 PM, and Resident #98 was on the unit when she left. She added she was sure of this because she had been waiting close to the door for the next shift to arrive and would not have let Resident #98 out of the secured unit. CNA #17 was interviewed on 06/15/2023 at 11:10 AM and stated Resident #98 had exit-seeking behaviors, but not daily. CNA #17 stated Resident #98 packed their belongings, stood by the exit door, and would say they needed to go home. Licensed Practical Nurse (LPN) #8 was interviewed on 06/15/2023 at 11:25 AM. LPN #8 stated WanderGuards were used on the secured unit for residents that were exit seeking. LPN #8 stated that at the time of admission, if the facility was alerted a resident had exit-seeking behaviors, a WanderGuard was discussed with the family. She stated that when the elopement assessment indicated a plan of care was needed, she followed those directions and implemented an elopement plan of care. A telephone interview was held with LPN #9 on 06/15/2023 at 12:30 PM, and she stated she had not worked the day Resident #98 eloped. LPN #9 reviewed the 02/04/2023 Progress Note related to exit seeking behaviors and acknowledged she had documented the note. LPN #9 defined Resident #98's exit-seeking behavior as going to the exit door and even rounding up other residents to leave. LPN #9 stated Resident #98's exit-seeking behavior usually occurred after supper when staff cleaned up the dining room, and the resident would gather personal belongings and state they were ready to go. LPN #9 stated that after Resident #98 was in bed, the resident stayed in bed for the entire night. A telephone interview was held with Resident #98's representative, Resident Representative (RR) #36, on 06/15/2023 at 1:01 PM. RR #36 stated the facility had informed him they thought the resident had walked out with other visitors. RR #36 stated Resident #98 had a history of wandering and going out alone, adding that when the resident lived with another family member, the family member would wake up, find the front door open, and Resident #98 was down the street. He stated those behaviors were why the family had chosen a locked unit. RR #36 stated that on admission he/she was very forthcoming about the resident's behavior and told not only the Admissions Liaison (AL) but other nurses and added he/she did not think the facility took Resident #98's flight risk as seriously as they should have. RR #36 stated anyone that saw Resident #98 knew the resident was physically able to get out of the building. The Director of Clinical Education (DCE) was interviewed on 06/15/2023 at 1:39 PM. The DCE stated she was responsible for training new nurses to complete assessments and when to do assessments for residents. She stated if any assessment directed nurses to proceed to care plan, she instructed nurses to make sure there had been a care plan developed for the problem. The DCE stated the nurse that admitted the resident was responsible for initiating the baseline care plan, then the baseline care plan went to the morning clinical meeting, where the problem and care plan would be discussed, and revisions made as needed. The DCE reviewed the baseline care plan and the elopement assessment for Resident #98 and stated that since the admission elopement assessment indicated the resident was at risk of elopement, the nurse should have included a focus area for elopement on the baseline care plan. The DCE also reviewed the comprehensive care plan and stated a care plan for elopement should have been developed prior to the resident's elopement on 02/06/2023. The DCE stated she interviewed Resident #98 who told the her that he/she waited for someone to go out and then followed the person out of the unit and the building. The DCE further stated, after Resident #98 left the secure unit, the receptionist likely thought the resident was just another visitor since Resident #98 left with visitors. The MDSC was interviewed on 06/15/2023 at 2:30 PM and stated that when an elopement assessment indicated a resident was at risk of elopement, the risk should be included on the baseline care plan and then carried to the comprehensive care plan. The MDSC confirmed she completed the admission elopement assessment for Resident #98 on 01/27/2023. The MDSC reviewed the baseline care plan completed on 01/27/2023 and confirmed she had not included elopement on Resident #98's baseline care plan but was unable to recall why she had not included the focus area of elopement. The MDSC reviewed the comprehensive care plan for Resident #98 developed by the facility and confirmed the focus area of elopement had not been added until 02/06/2023, after Resident #98 left the facility without staff's knowledge. The MDSC had no answer for why the comprehensive care plan had not included a focus area for elopement with interventions to mitigate the risk of elopement. The MDSC stated she did not know if having a baseline care plan or comprehensive care plan would have had influence in the resident's ability to elope but indicated a WanderGuard may have made a difference. The MDSC stated the interdisciplinary team (IDT), which consisted of the MDS nurse, the Unit Manager, Director of Nursing, and the Administrator, decided if a resident received a WanderGuard. A review of the medical record for Resident #98 failed to reveal documentation the IDT team had reviewed Resident #98 for a WanderGuard after the resident had been identified as a risk for elopement on 01/27/2023. The AL was interviewed on 06/15/2023 at 3:24 PM and confirmed she was responsible for reviewing records prior to a resident's admission. The AL stated any information she received from the RR during the admission process was shared with the nurse on the hall. The AL stated RR #36 was the person that completed Resident #98's admission paperwork. The AL stated RR #36 stated Resident #98 was an outdoor person and liked to walk but added she did not remember hearing anything about Resident #98 leaving a family member's house at night and going outside. The AL stated she made sure the nurses were aware Resident #98 liked to be outside and liked to walk but could not remember who had been told. A review of Resident #98's medical record revealed there was no documentation that reflected Resident #98's preference to walk or be outside. Dietary Aide (DA) #6 was interviewed on 06/16/2023 at 10:07 AM. DA #6 stated she was not at the facility when RI #98 eloped. DA #6 said she had not received education on elopement policies and protocols after Resident #98 eloped. The Director of Clinical Operations (DCO) was interviewed on 06/16/2023 at 10:44 AM and stated that on 02/06/2023, the day of Resident #98's elopement, an ad hoc (done for a particular purpose as necessary) quality assurance (QA) meeting was held and added she had been a part of that meeting. The DCO stated she had walked in the facility with the police officer and thought the eloped resident was a visitor. On 06/16/2023 at 11:40 AM, the Administrator stated that a resident that triggered for elopement and had exit seeking behaviors should receive a WanderGuard. The Administrator further stated that if a resident had no exit-seeking behaviors, such as pushing on the door, a WanderGuard may not be needed, if the resident resided on the secured unit. An observation and interview were held on 06/16/2023 at 1:06 PM with Front Desk Receptionist (FDR) #24. While standing at the doorway of the dayroom in the secured unit, FDR #24 stated she was unable to identify any of the residents in the secured unit. An interview was held with RR #23 on 06/16/2023 at 1:21 PM. RR #23 stated they had not received any instruction from the facility to be careful when leaving to avoid residents following them out. A telephone interview was held on 06/16/2023 at 1:25 PM with the police officer that returned Resident #98 to the facility on [DATE]. The officer stated he thought he had received a call from the community that a person that looked lost passed by a house, but added when he found Resident #98, they were confident in what they were doing. The officer stated he almost let Resident #98 go since there was no reason to detain the resident. The officer stated he searched the resident's personal items, found phone numbers, and called until he reached the RR, who told him where Resident #98 lived. The officer stated he returned the resident to the facility between 3:30 PM and 3:45 PM. The officer stated Resident #98 was found about two to three blocks from the facility or about a quarter of a mile. He was unable to remember exactly where he found the resident. The Director of Nursing (DON) was interviewed on 06/16/2023 at 1:37 PM. The DON stated he had been unaware Resident #98 was out of the building until the police officer brought the resident back to the facility. The DON stated if the resident triggered at risk for elopement, then he expected elopement to be included on the baseline care plan and on the comprehensive care plan. The DON stated decisions to place WanderGuards were made by the IDT. The DON stated the reason the investigation had not included family members was because no particular family member had been identified. He stated he had spoken to family members about elopement risks but had no documentation as evidence of the conversations. The DON stated it was probably an oversight that the investigation did not include a statement from the police officer that brought Resident #98 back to the facility. The DON stated it was not the practice of the facility to give visitors the code to enter and exit the secure unit, which meant staff had to push in the code to open the door. The DON stated staff were asked who opened the door, but no staff admitted they were the one that had let Resident #98 out of the unit. The DON stated that although Resident #98's elopement happened around 3:00 PM, which was at the time of shift change, he was unable to give a reason the 3:00 PM to 11:00 PM staff were not asked for witness statements. The DON stated the police officer told him Resident #98 was found in a neighborhood. He was not given an exact address or location. The DON stated he was unable to recall if family members of other residents in the secured unit were educated on not allowing residents to follow them out. During a follow-up interview with the DON on 06/16/2023 at 4:17 PM, the DON stated he had no documentation that he had spoken with family members about the elopement on 02/06/2023 to find out if any of those family members had noted the resident leaving the facility with them. The DON stated the sign on the facility's front door that cautioned visitors about letting residents out was placed on the front door on 02/06/2023, but there was not a sign placed on the secured unit door because staff were supposed to let people out and staff were expected to stop residents from exiting the secured unit. The Administrator was interviewed on 06/16/2023 at 4:57 PM and stated she would have expected to see Resident #98's elopement risk care planned on the baseline care plan to mitigate the resident's elopement risk and would have also expected the elopement care plan to be included on the comprehensive care plan. The Administrator stated that prior to Resident #98's 02/06/2023 elopement, when a resident was placed in the secured unit, staff thought the door was secure. Additionally, the Administrator indicated the door from the lobby to the outside would keep residents inside the facility. The Administrator stated that prior to Resident #98's elopement, WanderGuards were not used in the secured unit. The Administrator stated the expectation was for family members to receive education including being careful that no resident was following them out, and if they were unsure if the person leaving the secured unit was a visitor or a resident, to ask a staff member. 2. A review of the facility's four-point plan, executed after Resident #98's elopement on 02/06/2023, revealed, Staff to check the battery and the proper placement and functioning of all Code Alert bracelets [WanderGuards] every shift and daily respectively. A review of the Admission Record for Resident #320 indicated the facility admitted the resident on 06/09/2023 with diagnoses that included Dementia with Mood Disturbance and Unspecified Psychosis. On 06/12/2023, an Elopement Risk Evaluation was completed and indicated that although Resident #320 ambulated with a cane, the resident asked to go home, and based on the assessment, was determined to be at risk of elopement. A review of Resident #320's physician's orders revealed an order, dated 06/13/2023, to check WanderGuard for function every night. There were no orders to check for placement of the WanderGuard until 06/16/2023, when an order to check the placement of the WanderGuard every two hours was added. A review of Resident #320's comprehensive care plans revealed a Focus of I am at risk for elopement, initiated on 06/13/2023. On 06/13/2023, this care plan directed staff to check the resident's WanderGuard to make sure it was working properly. On 06/16/2023, the care plan was revised to direct staff to check the placement of the resident's WanderGuard every two hours, and if Resident #320 removed the WanderGuard, then 1:1 (one on one) observation should be initiated, and the Administrator and Director of Nursing were to be notified. A review of Resident #320's Progress Notes revealed a General Note, dated 06/13/2023 at 10:41 AM, that indicated a WanderGuard had been placed on Resident #320's left ankle due to the resident being an elopement risk. A review of the Progress Notes for Resident #320 from 06/13/2023 through 06/16/2023 revealed no documentation of the resident removing their WanderGuard and no identification of alternative interventions to keep Resident #320 safe. On 06/16/2023 between 1:03 PM and 1:10 PM, observations were made of residents on the secured unit and Resident #320 was not wearing a WanderGuard. Certified Nursing Assistant (CNA) #16 was interviewed on 06/16/2023 at 1:32 PM and confirmed Resident #320 did not have a WanderGuard on their left leg. CNA #16 stated she did not know why the resident was not wearing the WanderGuard and acknowledged the resident was supposed to have a WanderGuard. The DON was interviewed on 06/16/2023 at 4:17 PM and stated Resident #320 had removed his/her WanderGuard. An interview was held with Licensed Practical Nurse (LPN) #25 on 06/16/2023 at 5:58 PM. The LPN stated she had reassessed Resident #320's elopement status on 06/12/2023 because she thought the initial assessment had not been completed. The LPN stated Resident #320 received the WanderGuard because the resident looked like a visitor, the resident was new, and staff had no knowledge of the resident's personality or if the resident would try to elope. LPN #25 stated Resident #320 made comments about leaving and going home or to a family member's but had not pushed or pulled on the secured unit exit door. LPN #25 stated she was not sure exactly when Resident #320 pulled their WanderGuard off, but to the best of her knowledge, it had been off since Tuesday (06/14/2023) or Wednesday (06/15/2023). LPN #25 stated she had reported to the DON about Resident #320 taking the WanderGuard off, and the DON told her Resident #320 required reassessing due to not actively exit seeking and not wanting to wear the WanderGuard. LPN #25 was unsure if she had documented anything about Resident #320 taking the WanderGuard off but indicated the checks for the WanderGuard placement should be on the medication administration record (MAR). A review of Resident #320's Medication Administration Record [MAR] and Treatment Administration Record [TAR] for June 2023 revealed no information related to the WanderGuard placement checks. The DON was interviewed on 06/16/2023 at 6:09 PM and stated he found out Resident #320 had removed their WanderGuard on 06/14/2023 and had asked LPN #25 to place the WanderGuard back on the resident and report back if the resident removed the WanderGuard again. The DON stated LPN #25 had not reported back to him, and he had not followed up with the LPN. The DON stated he would have expected documentation to explain why Resident #320 had been reassessed three days after admission and would have expected documentation that indicated the resident would not keep the WanderGuard on. The DON stated he had no interventions documented that would keep the resident safe after the removal of the bracelet. The DON stated nurses were expected to check the function and placement of the WanderGuard every shift, and documentation should be on the MAR. The DON stated he was unaware the WanderGuard check for Resident #320 had not been completed. This deficient practice was cited as a result of complaint/report #AL00043300. ***************** On 06/19/2023 at 8:33 AM, the facility submitted an acceptable Removal Plan which included the following: 1. Resident #98 Actions: Resident #98, upon return to the center, was placed on one-to-one supervision that was documented on a resident observation form until a Wander-Guard was placed on the resident to ensure Resident #98's risk for elopement was reduced by the use of the departure alert system (Wander-Guard). The WanderGuard was checked for placement and functionality by the Director of Nursing Services (DNS) on 02/06/2023 and then every shift by charge nurse. The DNS completed a full body assessment upon the resident's return to the center, with no injury noted. A Nurse Practitioner was consulted, who assessed the resident to ensure the resident was without injury. Neurological checks were completed, and laboratory samples were obtained by a charge nurse on 02/06/2023. Resident #98's risk assessment was updated, and their care plan was reviewed and updated. The Medical Director and Responsible Party were notified of the event and a new plan of care was developed to include the use of a WanderGuard. During Clinical Start up, the Interdisciplinary Team (IDT) reviews Monday thru Friday the Elopement Risk Assessments completed on admission/readmission and for any quarterly assessments or significant change assessments to ensure the baseline care plan/comprehensive care plan reflects that the residents required interventions as identified on the Elopement Risk Assessment. 2. The Charge Nurses on each unit immediately completed a physical check to ensure all current resident were safe in facility on 02/06/2023. The Administrator and DNS ensured all residents with a physician order for a WanderGuard had a WanderGuard in place and the WanderGuard was functioning 02/06/2023. 3.On 02/06/2023, an immediate investigation was initiated by the Administrator to determine how Resident #98 was able to get outside. This investigation was finished on 02/13/2023. It was the belief of this facility that Resident #98 most likely pushed on the entrance door to the memory care after it was opened using the keypad. 4.On 02/06/2023, the Director of Nursing Services audited the elopement books to assure pictures and care plans were up to date to assure inclusion of all at-risk residents. Three residents were in the elopement book; all three had wander guards and care plans in pictures in the elopement book. 5.On 02/06/2023, all exits doors were checked by the Maintenance director to ensure the doors opened and closed properly. All doors were noted to be secured and functioning properly. The four wander guard doors are checked weekly and documented in Direct Supply TELS. The maintenance director checked 11 exterior doors and the entrance door to Memory care unit by using the keypad, opening the door, and watching the door close and then once the door closed, the maintenance director attempted to re-open the door to make sure it re-locked. The finding of this check was that for all 11 exterior doors and the entrance to the memory care unit, the keypads worked, the doors unlocked, opened, and closed, and relocked, and the closure mechanism worked. The WanderGuard apparatus was checked on the two exterior doors and two interior doors on 02/06/2023 by using a WanderGuard bracelet and walking up to the door to validate that the alarms sound, the door remains locked, and the door does not unlock until the code is entered. The facility has 11 passcode-protected exterior doors, two exterior doors located at the admissions entrance and the main entrance have WanderGuard and are also passcode-protected. Since 02/06/2023. The 11 passcode-protected exterior doors were checked daily. Each check validated that all 11 exterior doors and the entrance to the memory care unit that the keypads worked, the doors unlocked, opened, and closed, and relocked, and the closure mechanism worked. All doors passed inspection. Since 02/06/2023, the WanderGuard apparatus was checked weekly on the two exterior doors and two interior doors on 02/06/2023 by using a WanderGuard bracelet and walking up to the door to validate that the alarms sound, the door remains locked, and the door does not unlock until the code is entered. 6. On 02/06/2023, education was initiated by the Administrator regarding elopement guidelines. A continuation of education, to include elopement guidelines, was conveyed to Licensed Nursing, Certified nursing assistants, facility administrative staff including contracted dietary, housekeeping, and therapy staff by the DNS/Assistant Director of Nursing. Carefully closing doors and locking after entry and exit was included in the education 02/06/2023 provided to the facility staff including dietary, housekeeping, and therapy staff. Staff were informed that any resident with exit-seeking behaviors was to be reported to the charge nurse immediately. The charge nurse is to provide for safety, evaluate the resident and initiate a resident specific intervention based upon the specific need of the resident. On 02/06/2023, the Maintenance Director changed the code to the Memory Care Unit (MCU) entrance door and adjusted th[TRUNCATED]

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for 113 of 114 residents who received nourishment from the kitchen. The facility also failed to provide evidence of a routine cleaning schedule for the kitchen. Findings included: Review of a facility policy titled, Environment, revised September 2017, indicated, All food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition . The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . On 06/13/2023 at 9:30 AM, initial observation of the kitchen was conducted. The observations revealed the following: - A white plastic bin that contained bulk sugar had reddish-brown dried liquid and debris on the inside and outside of the lid. - A microwave had dried debris and grime on the front surface and interior. The door handle was slippery and greasy. - A black three-tiered mobile cart was observed to have dried debris on all three tiers. - A cart that housed the food processor was observed to have dried liquid and debris on the top counter. - A tall three compartment cart which housed clean dishes was observed to have dried debris on the inside ledge and on the top lids and surfaces. - The holder for a commercial can opener was observed to have grime, dried liquid, and debris on the outside and inside surfaces. - The front doors and handles of a bank of three refrigerators/freezers were observed to have grime and dried debris on the outside surfaces. on 06/15/2023 at 9:45 AM and had not been cleaned. On 06/15/2023 at 11:31 AM, the identified areas were observed to be in the same condition and were shown to the Regional Certified Dietary Manager (RCDM). On 06/15/2023 at 11:45 AM, the RCDM stated the kitchen needed a deep cleaning. On 06/16/2023 at 2:00 PM, the RCDM stated the kitchen used to have a cleaning schedule posted in the kitchen but the staff had stopped posting the schedule, but they had started posting the schedule again. On 06/16/2023 at 4:52 PM, the Administrator stated the RCDM informed her there were some cleaning issues in the kitchen. She stated she expected kitchen staff to keep the kitchen clean. On 06/17/2023 at 10:34 AM, the Director of Nursing stated he expected the kitchen to be kept clean. He added there had been no outbreaks of foodborne illnesses in the facility.

Based on observations, record review, and interviews the facility failed to ensure oxygen was administered at the prescribed flow rate, failed to ensure handheld updraft nebulizer masks were covered when not in use, and failed to ensure oxygen concentrator humidifier bottles were sufficiently filled for two (Resident #25 and Resident #92) of two residents reviewed for respiratory care. Findings included: During an interview on 06/15/2023 at 3:24 PM, the Director of Clinical Operations (DCO) said the facility did not have a policy for oxygen administration nor anything about keeping the handheld updraft nebulizer mask covered when not in use. 1. A review of an Admission Record indicated the facility admitted Resident #25 on 12/23/2021 with diagnoses that included Acute Respiratory Failure with Hypoxia, Bradycardia, and Chronic Obstructive Pulmonary Disease (COPD). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2023, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident had shortness of breath (trouble breathing) with exertion, when sitting at rest, and when lying flat and received oxygen therapy during the 14 days prior to the assessment. A review of Resident #25's comprehensive care plans revealed a Focus of alteration in respiratory status due to Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, risk for shortness of breath, continuous oxygen use, initiated on 01/05/2022. This care plan directed staff to administer medications as ordered and administer oxygen as needed per physician's order. A review of Resident #25's physician's orders revealed an order to administer oxygen at a rate of 2 (two) L/NC (liters via nasal cannula) continuously dated 01/22/2023 and an order to administer ipratropium-albuterol nebulizer solution four times a day dated 07/20/2022. On 06/13/2023 at 9:33 AM, Resident #25 was observed sitting up on the side of their bed. The resident said they had been at the facility for 14 months due to breathing problems and developed COPD due to a lifetime of smoking. Their oxygen was set at a rate of 3.5 (three and one-half) L/M (liters per minute) via nasal cannula per an oxygen concentrator. Resident #25's updraft mask was observed hanging on their bed rail and was uncovered. On 06/14/2023 at 10:30 AM, Resident #25 was observed sitting on the side of their bed receiving oxygen at a rate of 3.5 (three and one-half) L/M via nasal cannula, and their updraft mask was hanging on their side rail uncovered. The humidifier bottle on their oxygen concentrator was empty. During an interview on 06/14/2023 at 10:33 AM, Licensed Practical Nurse (LPN) #19 said Resident #25's oxygen should be set at a rate of 2 (two) L/M. LPN #19 then went to the resident's room and said their oxygen was set on 3.5 (three and one-half) L/M and confirmed the updraft nebulizer mask was uncovered. LPN #19 placed the updraft mask in a bag and changed the oxygen setting to 2 (two) L/M. She also confirmed that the humidifier bottle was empty and told the resident she would get them a new bottle. LPN #19 said the oxygen not being administered at the correct flow rate could cause the resident's carbon dioxide level to be higher, could cause difficulty breathing, and shortness of breath. She also said the updraft mask not being covered could cause the spread of infection, and the empty humidifier bottle could cause dryness. 2. A review of an Admission Record indicated the facility admitted Resident #92 on 12/23/2021 with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2023, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The resident had shortness of breath (trouble breathing) with exertion, when sitting at rest, and when lying flat and received oxygen therapy during the 14 days prior to the assessment. A review of Resident #25's comprehensive care plans revealed a Focus of alteration in respiratory status due to Chronic Obstructive Pulmonary Disease, Risk for shortness of breath, continuous oxygen use, initiated on 01/05/2022. This care plan directed staff to administer oxygen as needed per physician's order. A review of Resident #92's physician's orders revealed an order, dated 01/23/2023, to administer oxygen at 2.5 (two and one-half) L/NC (liters via nasal cannula) continuously and an order, dated 12/23/2022, to administer ipratropium-albuterol nebulizer solution four times a day. On 06/13/2023 at 11:28 AM, Resident #92 was observed lying in the bed on their right-side, receiving oxygen via nasal cannula per an oxygen concentrator at a rate of 4 (four) L/M. The humidifier bottle, dated 06/07/2023, was empty. The resident's updraft nebulizer mask was observed hanging on the head of their bed and was not bagged or covered. On 06/14/2023 at 10:29 AM, Resident #92 was observed lying in the bed on their right-side receiving oxygen via a nasal cannula per an oxygen concentrator at a rate of 4 (four) L/M. The updraft nebulizer mask was observed uncovered sitting on the top of the updraft machine. During an interview on 06/14/2023 at 10:34 AM, Licensed Practical Nurse (LPN) #19 said Resident #92's oxygen should be set at a rate of 2.5 (two and one-half) L/M. She then went into the resident's room and said their oxygen was set at a rate between 3.5 (three and one-half) to 4 (four) L/M and confirmed that their updraft nebulizer mask was uncovered, and the humidifier bottle was empty. She placed the updraft nebulizer mask inside a bag. During an interview on 06/16/2023 at 4:55 PM, the Director of Nursing (DON) said his expectation for administering oxygen was to administer the oxygen at the ordered flow rate, to cover the updraft nebulizer mask when not in use, and to make sure the humidifier bottle was sufficiently filled. He indicated the negative outcome of not administering the oxygen at the ordered flow rate was that it could exacerbate the resident's COPD, because there would not be enough carbon dioxide push-off due to getting too much oxygen. He also indicated that infection control issues could result from the resident's updraft nebulizer mask not being covered, and the empty humidifier bottle could cause nasal discomfort. During an interview on 06/17/2023 at 2:48 PM, the Administrator said she expected that oxygen be administered at the flow rate ordered by the doctor. She also said she expected updraft nebulizer masks to be properly stored in the bags that were provided, and the humidifier bottles needed to be replaced before they were empty. She indicated it was the charge nurse's responsibility to ensure that oxygen was administered at the ordered flow rate. She also indicated the night nurses were responsible for changing out the humidifier bottles.

Based on observation, record review, and interview, the facility failed to ensure the risks and benefits of side rails were reviewed with the resident or the resident representative and failed to ensure informed consent was obtained prior to the use of side rails for one (Resident #100) of three residents reviewed for side rails. Findings included: During an interview on 06/16/2023 at 4:42 PM, the Director of Nursing (DON) stated the facility did not have a policy regarding the use of side rails. A review of an Admission Record revealed the facility admitted Resident #100 on 01/17/2023 with diagnoses that included Metabolic Encephalopathy, Type Two Diabetes Mellitus, Unspecified Dementia, Adjustment Disorder with Anxiety, and Altered Mental Status. A review of a significant change in status Minimum Data Set (MDS), with an Observation end date of 03/17/2023, revealed Resident #100 had a Brief Interview for Mental Status score of five, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not walk and required extensive assistance or was dependent upon staff for most activities of daily living. The MDS indicated the resident received hospice care and that restraints were not used. Resident #100's Comprehensive Care Plan initiated on 01/22/2023 and revised on 04/19/2023 included a Focus for physical mobility deficit with interventions that included side rail to assist with mobility. A review of a Clinical Health Status Evaluation dated 01/17/2023 section titled Side Rail Assessment Screen indicated Resident #100 was able to turn from side to side with side rails. The assessment further indicated side rail safety was verified. The assessment indicated that based on the assessment findings the side rails were not a restraint and would be utilized to enable the resident to attain or maintain his/her highest practicable level. The assessment indicated the type of rails used would be quarter rails. The section for informed consent of the side rails that included the risks and benefits of implementation of side rails was blank and there was no evidence that informed consent was obtained for the use of the side rails. On 06/13/2023 at 2:14 PM, 06/14/2023 at 9:27 AM, 06/15/2023 at 8:23 AM, and 06/16/2023 at 9:15 AM, Resident #100 was observed in their bed with bilateral side rails in use. During an interview on 06/15/2023 at 3:39 PM, the Administrator stated the risks/benefits associated with side rail usage had not been provided to Resident #100 or the resident's representative and informed consent was not completed/signed until 06/15/2023. During an interview on 06/16/2023 at 3:37 PM, the DON stated there were no documentation which indicated informed consent for the use of side rails had been obtained from Resident #100 or the resident's representative since admission. He stated informed consent was required to be obtained prior to the use of side rails. During an interview on 06/18/2023 at 1:59 PM, the Administrator stated informed consent, including an explanation of risks and benefits, should be obtained prior to the use of side rails.

Based on resident record review, interviews, and review of the facility guidelines for Pain Management, the facility failed to ensure nursing staff sought an order for treatment for ice therapy for one (Resident #169) of one residents reviewed for concerns of pain. Findings included: A review of a facility guideline titled, Pain Management, dated January 2021, revealed the purpose was To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life. The guideline further revealed The nurse develops a plan of care for pain management based on findings from the evaluation with consideration of non-pharmacological interventions. The guideline indicated, The following is a list of non-pharmacological interventions that may be employed to manage pain either alone or as an adjunct to/with medications as needed. The list included Hot/Cold packs. A review of an Admission Record indicated the facility admitted Resident #169 on 01/06/2023 with diagnoses that included Aftercare Following Joint Replacement Surgery, Osteoarthritis of the Knee, Fibromyalgia (a disorder that affected muscles and soft tissue), and an Artificial Knee Joint. A review of a 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2023, revealed Resident #169 had a Staff Assessment for Mental Status (SAMS) score of 0, which indicated the resident was independent in making decisions regarding tasks of daily life. The assessment revealed the resident required extensive assistance of two staff members for bed mobility, transfers, toilet use, and bathing, required extensive assistance of one staff member for dressing and personal hygiene, required assistance of two staff members for walking in their room. A review of Resident #169's Baseline CarePlan, initiated on 01/06/2023, revealed the resident had barriers to transition that included pain management. The care plan indicated the resident had two incisions to the left knee related to surgery and pain at the surgical site. The interventions directed staff to administer pain medications as ordered and monitor for effectiveness and to document results and notify the physician for additional interventions. During a phone interview on 06/14/2023 at 2:58 PM, Resident #169 said they requested ice for their knee after knee surgery but was told a physician order was needed. Resident #169 said they were not provided ice therapy for their knee that night. A review of Progress Notes dated 01/06/2023 at 7:15 PM, revealed Resident #169 underwent a left total knee arthroplasty on 01/03/2023. Per the note, the resident and a family member were upset that ice therapy required an order by a physician. The note indicated the resident considered leaving against medical advice due to issues surrounding ice therapy and medical equipment and physical therapy not being present upon the resident's arrival. The note indicated Resident #169 had swelling of the left knee. A review of Resident #169's medical record revealed no evidence a physician order for ice therapy was sought by staff from 01/06/2023 through 01/07/2023. Resident #169's January 2023 Medication Administration Record (MAR) documented a pain level of four out of ten, on 01/06/2023 at bed time. During a phone interview on 06/15/2023 at 2:42 PM, Registered Nurse (RN) #26 stated she did not remember Resident #169. She said if ice therapy were ordered, she would provide it. She said if a patient asked for ice therapy and did not have an order for it, she would have sought an order for it. During an interview on 06/15/2023 at 1:52 PM, Licensed Practical Nurse (LPN) #4 stated residents required an order for ice therapy. She said if Resident #169 asked for ice therapy at night, an order could have been sought for it that night. During an interview on 06/15/2023 at 1:36 PM, RN #29 said she was the Director of Nursing (DON) at the time of Resident #169's stay at the facility, and she remembered discussing the resident during a morning meeting. She said she did not know why Resident #169 was not provided ice for their knee, since staff could have sought an order for it the night the resident was admitted . During an interview on 06/16/2023 at 4:52 PM, the DON said he was not the DON during Resident #169's stay at the facility. He indicated he expected that, if a resident needed ice therapy for their knee, a nurse would seek an order. He said the facility always had a physician on call. During an interview on 06/17/2023 at 3:00 PM, the Administrator stated if a resident requested ice therapy for their knee after knee surgery, she expected staff to get an order for ice therapy to assist with a resident's comfort. This was cited as a result of the investigation of complaint/report number AL00042995.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure activities of daily living (ADL) were provided to ensure good grooming for one (Resident #18) of three residents reviewed for ADL care. Specifically, the facility failed to ensure resident #18's fingernails were trimmed. Findings included: On 06/14/2023 at 3:28 PM, the Director of Clinical Operations (DCO) indicated the facility had no policy for the provision of ADL care to include nail care. The DCO stated the facility just provided the needed care. A review of the Admission Record indicated the facility admitted Resident #18 on 08/20/2018 with diagnoses that included a Stroke with Left Sided Hemiparesis, Dementia, Contracture to the Left Elbow, and the Need for Assistance with Personal Care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2023, indicated Resident #18 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The MDS indicated Resident #18 required extensive assistance from staff with personal hygiene. A review of Resident #18's care plan, with a revision date of 03/28/2023, revealed a focus area for Resident #18 that indicated the resident had a physical functioning deficit related to Left Hemiparesis (inability to use the arm and hand). Interventions directed staff to assist the resident with daily care as needed. Observations of Resident #18 on 06/13/2023 at 1:36 PM, on 06/14/2023 at 11:30 AM, and on 06/15/2023 at 9:48 AM revealed the resident's fingernails extended one-quarter to one-half inch beyond the tip of the finger. Resident #18's left hand was contracted (unable to move the extremity due to the joints being in a fixed position) with the fingernails touching the palm of the resident's hand. The edges of the nails appeared rough. During the observation on 06/13/2023 at 1:36 PM an interview with Resident #18 revealed the resident stated their fingernails needed to be trimmed. Certified Nursing Assistant (CNA) #2 was interviewed on 06/15/2023 at 9:12 AM. CNA #2 stated it was the responsibility of the CNA assigned to the resident to keep the resident's fingernails trimmed and clean. CNA #7 was interviewed on 06/15/2023 at 9:34 AM and stated the CNA that was assigned to the resident was responsible for providing nail care as needed. The CNA stated she usually checked residents' fingernails on assigned shower days. CNA #7 stated she had been assigned to care for Resident #18 on 06/12/2023 and on 06/15/2023, but neither of those days was the shower day for the resident. On 06/15/2023 at 9:48 AM, an observation of Resident #18's nails was conducted with CNA #7. CNA #7 stated Resident #18's fingernails were too long, and the fingernails should have been trimmed when the resident was scheduled for a shower. Resident #18 stated the fingernails were long, but they were not digging into (his/her) skin yet. The Administrator was interviewed on 06/16/2023 at 4:48 PM and stated she expected residents' nails to be cleaned and trimmed on a regular basis. An interview with the Director of Nursing (DON) was held on 06/17/2023 at 11:46 AM, and the DON stated his expectations were for nail care to be provided as needed when staff noted nails were long or dirty.

Based on interviews, record review, a review of the, Facility Investigative Files, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to identify physical abuse for RI (Resident Identifier)'s #4 and RI #7 perpetrated by a RI #3 a resident who resided on the secured Alzheimer's Care Unit (Dementia Unit) in the facility. This deficient practice affected RI #4 and RI #7 two out of six sampled residents for abuse and three out of six incident reports reviewed for abuse. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed: .Purpose: To prohibit and prevent abuse in accordance with the Federal and State Laws. Definitions: Abuse: The willful infliction of injury .resulting physical harm, pain, or mental anguish.Willful, as use in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.5. Identification . A resident to resident altercation will be reviewed as a potential situation of abuse. RI #4 was admitted to the facility on [DATE] and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/2021, the facility submitted an allegation of physical abuse to the State Survey Agency regarding RI #4, it documented: .CNA (Certificate Nursing Assistant) reported to charge nurse that resident RI #3 punched another resident, RI #4 in the nose. A review of the Investigation Template dated 10/14/2021 documented: . Investigation Summary: Both residents reside on the Memory Care Unit. (Resident's name) RI #4 was asleep in her/his bed prior to the incident. We believe that she/he got up to go to the bathroom and got confused when exiting the bathroom, entering RI #4's room. RI #4 attempted to stop her/him from entering when RI #3 reacted punching her/his . It is the determination of this facility that Abuse can't be substantiated. On 02/01/22 at 3:44 PM an interview was conducted with EI (Employee Identifier) #4 LPN, License Practical Nurse. Surveyor asked EI #4 to review an incident report dated 10/07/21 regarding RI #4. EI #4 was asked if RI #4 was assessed for an injury. EI #4 said yes. EI #4 was asked what happened. EI #4 said a CNA called her to the room and the resident, RI #4 said the resident came in the bathroom on his/her side . and hit her/him in the nose. EI# 4 was asked what type of injury she documented. EI#4 said, RI #4 had a nosebleed. On 02/01/22 at 4:41 PM an interview was conducted EI #1, Administrator and Abuse Coordinator. EI #1 was asked who was responsible for the investigation of the alleged allegation on 10/06/22. EI #1 said, as the abuse coordinator she was responsible for the investigation. EI #1 was asked did RI #4 have an injury to her nose. EI #4 said no visible injury, but nose was bleeding. EI #1 was asked why was RI #4's nose bleeding. EI #1 said, RI #4 said, RI #3 hit her/him in the nose. On 02/01/22 at 9:49 PM, a follow up interview was conducted with EI #1. EI #1 was asked if a resident hit another resident would that be considered abuse. EI #1 said yes. EI #1 was asked should this alleged allegation of abuse have been substantiated. EI #1 said, yes it should have been substantiated. On 10/26/2021, the facility submitted an allegation of physical abuse to the State Survey Agency regarding RI #4, it documented: Resident (Name) RI #4 reported to staff that RI #3 scratched her on her arm during the night . A review of the Investigation Template dated 11/2/21 documented: . Investigation Summary: Both RI #3 and RI #4 reside on the Memory Care Unit. RI #4's roommate said that RI #3 tried to get in the bed with RI #4 and when she refused to let him/her in the bed, RI #3 scratched her/him. It is the determination of this facility that abuse can't be substantiated . On 02/02/22 at 9:17 AM an interview was conducted with EI #3, LPN, Unit Manger. EI #3 was asked how did she become aware of the incident on 10/26/21. EI #3 stated RI #4 or her/his roommate told her RI #3 scratched her/him the night before on 10/25/21. EI #3 was asked when she assessed RI #4 did, he/she have any injury. EI #3 said yes, scratch to her/his right arm. EI #3 was asked if a resident scratched another resident was that considered abuse. EI #3 said yes, absolutely. On 02/02/22 at 9:54 AM, an interview was conducted with EI #1. EI #1 was asked who was responsible for completing this investigation. EI #1 said she was responsible for completing the investigation. EI #1 was asked what type of allegation was reported. EI #1 said it was a physical abuse allegation. EI #1 was asked what did she determine happened during the incident. EI #1 said, RI #4 said, RI #3 scratched him/her on the arm. EI #1 was asked if RI #4 had an injury to his/her arm. EI #1 said yes, a scratch to his/ her right forearm. EI #1 was asked what was her determination after the investigation. EI #1 said she put it was unsubstantiated at that time. EI #1 was asked should, the alleged allegation have been substantiated. EI #1 said, it should have. RI #7 was admitted to the facility on [DATE] and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/10/22, the facility submitted an allegation of physical abuse to the State Survey Agency regarding RI #7, which documented: Resident (name) RI #3 hit Resident (name) RI #7 in the nose causing a nosebleed . A review of the Investigation Template dated 01/17/22 documented: Investigation Summary: . It was noted that RI #3 was sitting in the chair in the dining room that RI #7 normally sits in. On the following day, EI #1 spoke with RI #7 about the incident, and he/she didn't remember being hit by another resident . It is the belief of this facility that RI #3 had increased anxiety when approached by RI #7 about being in his/her chair. We do not believe this as a premeditate act on RI #3's part. The allegation of abuse in this incident can't be substantiated . On 2/1/22 at 3:47 PM an interview was conducted with EI #3, LPN. EI #3 reported that on 1/10/22 RI #3 was sitting in another resident's chair, RI #7. Previously RI #7 would ask resident sitting in his/her chair to move. EI #3 said, no staff were in the dining area and was assuming that RI #7 tried to get RI #3 out of his/her chair and RI #3 hit RI #7. EI #3 continued, that she was in the office and heard a resident say something about hitting someone and she ran into the dining area. When she came into the dining room, she saw RI #7 was sitting in a chair by the sink and his/her nose was bleeding and RI #4 was sitting to RI #7's left side. Another resident reported that RI #4 hit RI #7. On 2/1/22 at 4:30 PM an interview was conducted with EI #1. EI #1 was asked, regarding the incident on 1/10/22, did she interview witnesses. EI #1 replied, yes and all the residents that were in the dining room could say was he/she hit him/her and not provide any details. EI #1 was asked, was this incident substantiated. EI #1 replied, no. EI #1 was asked, should a witnessed incident of a resident hitting another resident be a substantiated allegation of abuse. EI #1 replied, she did not think so, because there was no intent by the resident, he/she just reacted. On 2/1/22 at 5:35 PM a follow-up interview was conducted with EI #1. EI #1 reported that after speaking with surveyor, she got clarification and the incident on 1/10/22 with RI #4 and RI #7 should have been substantiated since it was witnessed physical abuse. EI #1 was asked, why was the incident not initially substantiated. EI #1 replied, the facility staff knew that it happened and took actions to protect the residents. EI #1 continued, it was not substantiated because she did not find that RI #4 had intent to harm RI #7. F600 was cited as a result of the investigation of complaint/report number #AL 684

Based on interviews, review of the Online Incident Reporting System Reports, and a review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure three allegations of abuse were reported to the State Survey Agency within the two-hour time frame. This deficient practice affected three out of six abuse allegations reviewed for being reported within the appropriate time frame. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed: .Purpose: To prohibit and prevent abuse . in accordance with the Federal and State Laws. Definitions: Abuse: The willful infliction of injury, .resulting physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately. Immediately reporting all alleged violations to the Administrator, designee, state agency .within specified timeframe. All alleged violations -immediately but not later than 1. 2 hours if the alleged violation involves abuse . Review of the Online Incident Report System Report revealed an allegation of physical abuse occurred on 09/26/21 at 5:18 p.m. The allegation of physical abuse was not reported to the State Agency until 09/27/21 at 11:15 a.m. On 02/01/22 at 2:01 PM an interview was conducted with EI (Employee Identifier) #1, Administrator and Abuse Coordinator. EI #1 was asked what was the date of this alleged abuse or incident. EI #1 said 09/26/21. EI #1 was asked what was alleged. EI #1 said physical abuse. EI #1 was asked when was this alleged abuse allegation reported to the SA (State Agency). EI #1 said on 09/27/21. EI #1 was asked was this alleged abuse allegation reported to the SA within the two-hour time frame. EI #1 said no because it was identified by a staff member on 09/26/21. EI #1 was asked should this alleged abuse allegation have been reported to her. EI #1 said yes it should have on 09/26/21. EI #1 was asked did the facility follow the policy regarding the reporting of alleged abuse violations. EI #1 said no, the policy was not followed. Review of the Online Incident Report System Report revealed an allegation of physical abuse occurred on 10/08/21 at 8:30 a.m. The allegation of physical abuse was not reported to the State Agency until 10/08/21 at 2:12 p.m. On 02/02/22 at 2: 16 PM an interview was conducted with EI #1. EI #1 was asked what was the date of this alleged abuse or incident. EI #1 said it happened on 10/08/21. EI #1 was asked what was the alleged allegation. EI #1 said physical abuse. EI #1 was asked when she reported this alleged abuse allegation to the SA. EI #1 said, she reported it to the SA's office at 2:12 p.m. EI #1 was asked what time did the alleged incident happen. EI #1 said at 8:30 a.m. EI #1 was asked did she reported this alleged abuse allegation to SA within the two-hour time frame and according to the abuse policy. EI #1 said, no she did not. Review of the Online Incident Reporting System Report revealed an allegation of physical abuse occurred on 10/06/21 at 7:40 PM. The allegation of physical abuse was not reported to the State Agency until 10/07/21 at 8:30 AM. On 02/02/22 at 2:16 PM an interview was conducted with EI #1. EI #1 was asked what was the date of the alleged abuse or incident. EI #1 said 10/06/21. EI #1 was asked what was alleged. EI #1 said physical abuse. EI #1 was asked when was this alleged abuse allegation reported to the SA. EI #1 said the next morning on 10/7/21. EI #1 was asked when should this alleged abuse allegation have been reported to the SA. EI #1 said on 10/06/21. EI #1 was asked why were these three abuse allegations not reported to our office within the two-hour time frame per the facility's policy. EI #1 said they were not reported to her timely, so she could not report the to our office in the two-hour time frame. F609 is cited as a result of the investigation of complaint /report number AL 594

Based on interview, record review, and review of a facility policy titled Weight and Height of Resident, Obtaining the facility failed to ensure weekly weights were obtained for Resident Identifier (RI) #12 as ordered by physician. This affected one of three residents reviewed for following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings Include: A review of a facility policy titled Weight and Height of Resident, Obtaining with an effective date of March 21, 2021 revealed: POLICY The resident height and weight will be determined upon admission and at regular intervals throughout the resident's stay in the center. PURPOSE The purpose of this policy is to: provide an ongoing record of the resident's body weight as an indicator of the nutritional and hydration status and medical condition of the resident, . GENERAL INFORMATION . Residents are weighed . as ordered by the attending physician to monitor the resident ' s condition. RI #12 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #12's Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #12's Weights and Vitals Summary revealed weight recorded on 1/7/2022. No other weights were recorded. On 2/2/22 at 9:35 AM an interview was conducted with EI #10, Certified Nursing Assistant. EI #10 was asked, what was the facility's process for obtaining weights on newly admitted residents. EI #10 replied, when residents were admitted , weights and vitals were measured, and then the unit managers made a list of residents who needed to be weighed weekly or monthly. EI #10 was asked, was RI #12 on the list of residents for weights. EI #10 replied, she did not recall. On 2/2/22 at 3:25 PM an interview was conducted with EI #2, Director of Nursing Services. EI #2 was asked, about weekly weight documentation on 1/13/22 for RI #12 and she reported that she did not obtain the weight because it was scheduled wrong, and it was the middle of the night. EI #2 was asked, why was it important to obtain weekly weights when a resident was admitted . EI #2 replied, to get a baseline of the resident's weight. EI #2 was asked, how many weights were obtained for RI #12 during his/her stay at the facility. EI #2 replied just one, on admission. EI #2 was asked, why was it not being done weekly as ordered by the physician. EI #2 replied she did not know. On 2/3/22 at 8:15 AM an interview was conducted with EI #11, RN, Unit Manager. EI #11 was asked, when a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #12 replied, on admission and weekly, and it was on the Electronic Medication Administration Record (eMAR) for nurses to obtain or have CNA obtain. On 2/3/22 at 11:30 AM an interview was conducted with EI #4, RN Unit Manager. EI #4 was asked, what was facility's process for obtaining weights for newly admitted residents. EI #4 replied, all newly admitted residents should be weighed upon admission and then if the physician ordered weekly weights, weights were obtained weekly. EI #4 was asked, why were weekly weights not obtained for RI #12 during his/her stay as ordered by the physician. EI #4 replied, the nurse that saw it on the eMAR and could have asked a CNA to obtain, but not have followed up on it. EI #4 added, she was not really sure what happened and normally the nurse that was on the medication cart was responsible. EI #4 was asked, what was the potential harm to a resident when a physician ordered weekly weights and only an admission weight was obtained. EI #4 replied, the resident could have unrecognized weight gain or weight loss. On 2/3/22 at 1:00 PM a follow-up interview was conducted with EI #2. EI #2 was asked, what was facility's process for obtaining weights for newly admitted residents. EI #2 replied, the policy was for all residents to be weighed on admission and then monthly or by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 replied, it would depend on the resident's diagnosis. EI #2 was asked, could the resident have unrecognized weight gain or loss if weekly were not obtained as ordered. EI #2 replied, yes.

Based on interview, record review, and review of facility policy titled Notification of Change in Patient/Resident Health Status the facility failed to ensure Resident Identifier (RI) #12's lab results reported on 1/27/2022 at 6:12 PM were reviewed and communicated with the physician before 1/31/2022. This affected one of three residents reviewed for timely lab review. Findings Include: A review of facility policy titled Notification of Change in Patient/Resident Health Status with a date of June 2017 revealed: Purpose To ensure all interested parties are informed of the patient ' s/resident ' s change in health status so that a treatment plan can be developed which is in the best interest of the patient/resident. Process The center will consult the resident ' s physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is: . C) A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Depending on the nursing assessment appropriate notification may be immediate to 48 hours . RI #12 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #12's Order Recap Report for the month of January 2022 revealed a Prescriber Entered order dated 1/25/22 for Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) entered by Employee Identifier (EI) #5, Physician. A review of RI #12's laboratory results revealed results for RI #12 with a DATE DRAWN of 1/27/2022 2:30 AM and DATE REPORTED 1/27/2022 6:12 PM. The results included out of range results of: POTASSIUM of 6.2 mmol/L (millimoles per liter); Urea Nitrogen (BUN) 82 mg/dl (milligrams per deciliter); and Creatinine 3.32 mg/dL. On 2/1/22 at 5:15 PM surveyor requested EI #9, Licensed Practical Nurse to print lab results for RI #12. On 2/2/22 at 5:50 PM EI #9 reported that she was unable to find the results and requested labs to be faxed from laboratory and had not received. She called lab back at that time and lab results were faxed and received. On 2/2/22 at 8:30 AM an interview was conducted with EI #6, Client Services with the laboratory. EI #6 reported RI #12's blood sample was received to the lab on 1/27/22 at 2:33 PM. She reported that the results were communicated on the web portal 1/27/22 at 6:12 PM; and then the results were faxed on 1/28/22 at 2:37 AM and went through at 3:56 AM on 1/28/22. EI #6 was asked, what was the critical level for potassium. EI #6 replied, less than 2.8 mmol/L or greater than 6.2 mmol/L. On 2/2/22 at 9:50 AM an interview was conducted with EI #9, Licensed Practical Nurse (LPN). EI #9 was asked, what was the facility's process for ordering lab and ensuring results were communicated as needed timely. EI #9 replied, normally the Physician entered the order in the computer and the nurse assigned saw the order and got a form from the lab book and entered the resident information and order information and then placed the form in the lab book under the dated tab. EI #9 continued, that after labs were drawn the unit managers typically reviewed results and the lab company faxed labs to the unit manager's office and the unit manager reviewed and addressed as needed. EI #9 reported the unit manager was EI #4. The surveyor and EI #9 reviewed the lab book and noted lab was signed as completed on 1/27/22 and form completed. EI #9 was asked, when lab was ordered on 1/25/22, drawn on 1/27/22, resulted on 1/27/22, when should abnormal results be identified and communicated with physician. EI #9 replied, the same day results received, 1/27/22. On 2/2/22 at 10:30 AM an interview was conducted with EI #7, Registered Nurse. EI #7 reported that on 1/26/22 she saw a lab was ordered for RI #12 and no lab form was completed so she completed the form and she followed up to ensure the lab was drawn on 1/27/22. EI #7 reported that she did not see the results and did know the results were available until Monday, 1/31/22 when the EI #8, Certified Registered Nurse Practitioner asked for the results and after she could not find the results, EI #8 went to find them. EI #8 came back and told her that the potassium was high, and she was going to call EI #5, and the decision was made to send RI #12 to the emergency room because the son wanted RI #12 to go anyway. On 2/2/22 at 5:15 PM an interview was conducted with EI #8, CRNP. EI #8 reported that on 1/31/22 the nurse approached her and said that RI #12's son was concerned about a gradual decline and EI #5 had seen RI #12 on 1/25/22. EI #8 continued, on 1/25/22 EI #5 spoke with the son, and the labs were ordered. EI #8 continued, on 1/28/22 EI #5 saw RI #12 and he noted that RI #12 was still having confusion and the labs were not available. EI #5 added, on 1/31/22 she saw RI #12, reviewed the labs, and noted that he/she had elevated potassium and creatinine. When she went to look for the labs the paper copy was not on the chart, but she went to EI #2, Director of Nursing Services (DNS) and got the password for the labs and reviewed the results. On 2/2/22 at 5:45 PM an interview was conducted with EI #5, Physician. EI #5 was asked, a lab order was entered on 1/25/22 for CMP and CBC for RI #12, when did he expect the results to be available to him. EI #5 replied, a few days. EI #5 added, that he saw RI #12 and he/she seemed ok, but he ordered labs after talking to his/her son. EI #5 continued that on 1/28/22 he talked to RI #12's other son and saw RI #12. EI #5 continued, when he saw RI #12 that he/she seemed ok but talking to the sons, he/she had been having some delusions and confusion. EI #5 reported that he checked the chart for labs and did not find the labs, and that he was waiting for labs because he was concerned about infection but later found out RI #12 was having other problems. He reported that he tried to login to the labs database and was unable to because of password problems. On the following Monday, 1/31/22, the CRNP saw RI #12, reviewed the labs, and discussed it with him. EI #5 was asked, would having access to the lab on Friday, 1/28/22 changed the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #5 added, when RI #12 was sent to the hospital it was not sending her because she was critical, but it was after a discussion and he and the CRNP thought it was best. EI #5 was asked, when the labs were not available on Friday, 1/28/22, did that cause a delay in treatment. EI #5 replied, yes. On 2/3/22 at 11:30 AM an interview was conducted with EI #4, Licensed Practical Nurse (LPN), Unit Manager. EI #4 was asked, when a physician ordered lab test, what was the facility's process to review and communicate lab results. EI #4 replied, once labs were obtained, the lab company faxed the labs to the fax machine in the manager's office and the labs were taken and reviewed for critical labs to call immediately and all other labs were put on a clip board at nurses' desk for physician review. She reported that when she was not here, the other unit manager should check fax, but anyone could do it. EI #4 was asked, why were labs not available to the physician for resident RI #12 on 1/28/22 when he tried to review. EI #4 replied, she did not know, she reported she was out with sick last week and returned on 1/31/22. EI #4 was asked, what was potential harm to a resident with elevated potassium of 6.2 which is critical at 6.3 and elevated BUN and creatinine when labs were drawn on 1/27/22 reported on 1/27/22, physician was unsuccessful obtaining results when attempted to review on 1/28/22, and then reviewed on 1/31/22 by the Certified Registered Nurse Practitioner. EI #4 replied, the high potassium could have caused cardiac issues. EI #4 was asked, could it have caused a delay in treatment. EI #4 replied, if the physician did not review results then he would not know that it needed to be treated. On 2/3/22 at 1:00 PM an interview was conducted with EI #2, DNS. EI #2 was asked, when a physician ordered labs, what was the facility's process to review and communicate lab results. EI #2 replied, the nurses should get the report from the fax or the lab website and call the provider or place the results in the binder at the nurses' desk. EI #2 continued, anything that was abnormal or that was a big change was called to the provider and all critical were reported immediately. EI #2 was asked, why were labs not available to the physician for RI #12 on 1/28/22 when he tried to review. EI #2 replied, the labs were not received by fax and not critical, so they were not called and on Monday 1/31/22 EI #8 and some nurses were having problems with the lab's website password, so it was given to the nurses and posted inside the lab books. EI #2 was asked, what was potential harm to a resident with elevated potassium of 6.2 which is critical at 6.3 and elevated BUN and creatinine when labs were drawn on 1/27/22 reported on 1/27/22, physician was unsuccessful obtaining when attempted to review on 1/28/22, and then reviewed on 1/31/22 by CRNP. EI #2 replied, the physician could have looked at labs on the Friday, but he did not feel like there was a problem. If the potassium, BUN, creatinine levels were critical it could have caused other problems - potassium can cause cardiac issues and creatinine and BUN can cause kidney failure. EI #2 was asked, should the labs results have been on the physician's notebook on Friday, 1/28/22. EI #2 replied, yes, when they became available. EI #2 was asked, when did they become available. EI #2 replied, at the time of result.

Based on interviews, review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, Resident Identifier (RI) #1's medical record, and the facility's investigation file, the facility failed to ensure RI #1 was not abused by Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) on 7/1/2021. On 7/1/2021 around 2:00 PM, EI #3, a CNA witnessed EI #4, a CNA hit RI #1. EI #4 was then witnessed to restrain the resident by holding RI #1's arms to his/her chest. When the resident asked EI #4 to stop, EI #4 spanked (struck) the resident's hands several times as if he/she was a child. EI #4 was overheard telling the resident, You ain't stronger than me old (man/lady). This deficient practice placed RI #1, one of four sampled residents reviewed for abuse, in immediate jeopardy, as the situation was likely to cause serious injury, harm, impairment, or death. On 8/26/2021 at 7:12 PM, the facility's Administrator, Director of Nursing, Assistant Director of Nursing and a Corporate staff member were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019, documented, Purpose: To prohibit and prevent abuse, . in accordance with Federal and State Laws. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Mental abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Physical Abuse: Includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior . RI #1 was readmitted to the facility on [DATE]. On 7/5/2021, the facility submitted an allegation of physical abuse to the State Survey Agency regarding RI #1. According to the report, . At 7:49 am on 7/5/2021, (EI #3) reported to DNS (Director of Nursing Service) that on 7/1/2021 (EI #4) popped/spanked (RI #1) on the hand and was holding (him/her) down . The facility's INVESTIGATION TEMPLATE dated 7/14/2021, documented, . Investigative Summary: . On 7/5/2021, the Administrator and DNS spoke with (EI #3), CNA. She stated on 7/1/2021, (EI #4) asked her to come assist with providing care to (RI #1). She stated after she entered the room, (EI #4) spanked (RI #1) on the hand several times and was holding (him/her) down saying you ain't stronger than me old (man/lady). The Administrator asked (EI #3) to demonstrate how (EI #4) held (RI #1) down. (EI #3) crossed the Administrator's arms over her chest and pressed down not allowing the Administrator to move. On 7/13/2021, the Administrator spoke with (EI #3). She stated that (RI #1) was hitting out and saying stop prior to (EI #4) spanking (his/her) hands and restraining (him/her). The Director of Nursing (DNS) completed a skin assessment on (RI #1) and found 4 small brown discolored (round in shape) to the (r) (right) forearm and one discolored area (round in shape) on the (L) (left) wrist . It is the determination of this facility that the bruising noted on (RI #1's) forearm and wrist were consistent with the timeline and actions reported by CNA (EI #3). This Allegation was Substantiated . In an interview on 8/3/2021 at 2:48 PM, EI #3, a CNA was asked about the incident between RI #1 on EI #4. According to EI #3, EI #4 asked her to come into RI #1's room to assist her with the resident's bed bath. When RI #1 cursed at and became combative with EI #4, EI #4 told RI #1 that she was not stronger than her and then EI #4 held RI #1 down. EI #3 stated as she stood against the wall, she didn't know why this was happening. EI #3 stated while EI #4 held RI #1's arm against the resident's chest, EI #4 stated, I am stronger than you, old (man/lady). EI #4 then popped RI #1 on his/her hand first. Then EI #4 turned RI #1 over and shoved the resident in the direction of EI #3. When asked how EI #4 popped RI #1, EI #3 stated with an open hand, multiple times. When asked how the resident responded after being popped, EI #3 stated RI #1 didn't say anything else. When asked if what she observed was abuse, EI #3 said yes. When asked what kind of abuse, EI #3 replied, physical and mental. EI #3 was asked what the mental abuse was, and she stated it was EI #4 hollering at RI #1 and what she said. In a telephone interview on 8/4/2021 at 1:03 PM, EI #4, a CNA denied abusing RI #1 on 7/1/2021. The DIVERSICARE PROGRESSIVE DISCIPLINE FORM for EI #4 indicated the CNA's employment with the facility was terminated on 7/16/2021 for a Category 1 Violation: 1.1 Patient/resident abuse . The form further documented, . Summary of Incident: Team Member used unnecessary force while providing care to a resident . During an interview on 8/5/2021 at 8:40 AM, EI #1, the Administrator acknowledged that she was the facility's Abuse Coordinator. When asked how she became aware of the incident between RI #1 and EI #4, EI #1 stated on 7/5/2021, it was reported to her by the DNS, EI #2 and she and EI #2 both went into the office to talk with EI #3. According to EI #1, EI #3 stated EI #4 held RI #1's hands to his/her chest, to keep the resident from moving and EI #3 stated, You ain't stronger than me old (man/lady). EI #1 stated the allegation of abuse was substantiated based on the bruising to the resident. RI #1's Shower Sheet dated 7/5/2021 completed by EI #2, the DON documented Bruise on top (L) (left) wrist 4 small brown discolored areas to (R) (right) forearm (L) wrist Bruise is blue in color and approx (approximately) 2cm (centimeter) & 2m (meter) round. ************************* According to the facility's TIMELINE, the following corrective actions were implemented: . 7/5/2021 - (EI #4) WAS INTERVIEWED AND SUSPENDED IMMEDIATELY AFTER INCIDENT WAS REPORTED. SKIN ASSESSMENT COMPLETED ON (RI #1). 7/6/2021 - INCIDENT INVOLVING (RI #1) WAS DISCUSSED IN DAILY CONNECT MEETING. 7/6 - 7/13/2021 - INVESTIGATION WAS CONDUCTED. 7/14/2021 - FOLLOW-UP WAS SUBMITTED TO ADPH ( Alabama Department of Public Health). CONTACTED (EI #4) TO COME IN AND DISCUSS OUTCOME OF INVESTIGATION. APPT SET FOR 7/16/2021. 7/16/2021 - CNA (EI #4) WAS TERMINATED. 7/16/2021 - PROGRESSIVE DISCIPLINE AND ONE TO ONE TRAINING WITH (EI #3) ON WHAT CONSTITUTES ABUSE AND REPORTING ABUSE PER CMS (Centers for Medicare & Medicaid Services) GUIDELINES WAS COMPLETED. 7/16/2021 - IN-SERVICE TRAINING ON HOW TO CARE FOR (RI #1), INCLUDING INTERVENTIONS AND APPROACHES ON HANDLING AGGRESSIVE BEHAVIORS WAS DONE WITH CNA'S (CNAs) AND NURSES. ************************* After review of the facility's corrective action plan, investigation file, in-service/education records, Quality Assurance plan, and resident and staff interviews, the facility implemented corrective actions from 7/5/2021 to 7/16/2021, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of complaint/report number AL 451.

Based on interviews, review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, the In-Service Training Record, the facility's assignment sheets and Employee Identifier (EI) #4's time sheet, the facility failed to ensure EI #3, a Certified Nursing Assistant (CNA) implemented two of seven components of the facility's abuse policy. On 7/1/2021 around 2:00 PM, EI #3, a CNA witnessed EI #4, a CNA hit Resident Identifier (RI) #1. EI #4 was then witnessed to restrain the resident by holding RI #1's arms to his/her chest. When the resident asked EI #4 to stop, EI #4 spanked (struck) the resident's hands several times as if he/she was a child. EI #4 was overheard telling the resident, You ain't stronger than me old (man/lady). EI #3 had been previously trained on the facility's abuse policy and procedures; however, EI #3 failed to identify the incident as abuse and immediately report the allegation to the facility's Abuse Coordinator. Because of these failures, EI #4, a CNA, was not removed from direct resident care and suspended as directed by the facility's policy. These deficient practices placed RI #1; one of four sampled residents reviewed for abuse, in immediate jeopardy, as the situation was likely to cause serious injury, harm, impairment, or death. On 8/26/2021 at 7:12PM, the facility's Administrator, Director of Nursing, Assistant Director of Nursing and a Corporate staff member were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: The facility's Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019, documented, Purpose: To prohibit and prevent abuse, . in accordance with Federal and State Laws . 1. Protection First and foremost the resident/patient will be immediately assessed and removed from any potential harm. Examine the resident for any sign of injury, including a physical assessment or psychosocial assessment if indicated . If the suspected perpetrator is a team member, the Administrator/Director of Nursing or designee shall place the team member on immediate investigator suspension while completing the investigation . 5. Identification If actual or alleged violation occurs the resident will immediately be assessed and removed from any potential harm (as applicable). Education provided assists team members in identifying abuse . Education provided assists team members in identifying different types of abuse - mental/verbal abuse, . physical abuse, . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately. Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies within specified timeframes . On 7/1/2021 around 2:00 PM, EI #3, a CNA witnessed EI #4, a CNA hit RI #1. EI #4 was then witnessed to restrain the resident by holding RI #1's arms to his/her chest, this caused the resident not to be able to move. When the resident asked EI #4 to stop, EI #4 spanked (struck) the resident's hands several times as if he/she was a child. EI #4 was overheard telling the resident, You ain't stronger than me old (man/lady). After EI #3 consulted with someone outside of the facility, she finally reported the allegation of abuse to the facility's Director of Nursing (DON) on 7/5/2021. EI #4, who was in the facility working was immediately removed from the facility and placed on suspension pending the results of the investigation. Refer to F600 In an interview on 8/3/2021 at 2:48 PM, EI #3, a CNA was asked about the incident between RI #1 and EI #4. According to EI #3, EI #4 asked her to come into RI #1's room to assist her with the resident's bed bath on 7/1/2021 around 2:00 PM. When RI #1 cursed at and became combative with EI #4, EI #4 told RI #1 that she was not stronger than her and then EI #4 held RI #1 down. EI #3 stated as she stood against the wall, she didn't know why this was happening. EI #3 stated while EI #4 held RI #1's arm against the resident's chest, EI #4 stated, I am stronger than you, old (man/lady). EI #4 then popped RI #1 on his/her hand first. Then EI #4 turned RI #1 over and shoved the resident in the direction of EI #3. When asked how EI #4 popped RI #1, EI #3 stated with an open hand, multiple times. When asked how the resident responded after being popped, EI #3 stated RI #1 didn't say anything else. When asked if what she observed was abuse, EI #3 said yes. When asked what kind of abuse, EI #3 replied, physical and mental. EI #3 was asked what the mental abuse was, and she stated it was EI #4 hollering at RI #1 and what she said. EI #3 was asked if she did or said anything during the incident. EI #3 replied, she did not. EI #3 acknowledged that two days later she reported what she saw to EI #2, the DON. When asked why she did not report the incident when it first happened, EI #3 stated at the time, she knew it should be reported but she didn't think it was abuse. When asked, at what point did she realize it was abuse, EI #3 stated it was after she got home and realized EI #4 had spanked RI #1 like a child, that she felt it was abuse. EI #3 explained that it bothered her over the next couple of days and she mentioned it to someone not affiliated with the facility, who told that it was abuse. During an interview on 8/4/2021 at 4:53 PM, EI #2, the DON was asked about the incident with RI #1. According to EI #2, as she was at the font doing temperatures on 7/5/2021, EI #3, a CNA approached her and stated she was leaving because of the way EI #4, a CNA, treats the residents. EI #2 stated she took EI #3 into her office to ask her what happened. It was at this time, EI #3 informed EI #2 that EI #4 had held RI #1 down during care and told the resident, you are not stronger than me old (man/lady). EI #2 stated she pulled EI #4 from patient care, had her to write a statement and sent her home (suspended). EI #2 also had EI #3 write a statement. Then EI #2 informed the Administrator, EI #1. When asked when did EI #3 report the incident occurred, EI #2 stated she said it happened on Thursday (7/1/2021). When asked why she (EI #3) waited to inform someone, EI #2 replied that she asked EI #3 and she stated she didn't know. EI #2 stated she reminded EI #3 that she had just gone through orientation, where abuse and neglect was discussed and that she was supposed to report it immediately. According to EI #2, EI #3 acknowledged the recent abuse and neglect training. When asked did EI #3 follow the facility's abuse policy, EI #2 said no because she did not report it immediately. EI #2 was asked how she participated in the investigation. EI #2 replied, she suspended EI #4, disciplined EI #3 and conducted a body audit (assessment) of RI #1. During the body audit, EI #2 stated RI #1 had discoloration on the top of both hands and a blue, quarter-size bruise on the left wrist. EI #2 stated this bruise was fairly new because of the color; it appeared to be about a day or two old. EI #2 stated there were four other smaller old discolored areas that were brown in color on the top of the resident's right forearm. According to EI #2 these discolored areas were consistent of someone holding RI #1 down. When asked if EI #4 followed the facility's abuse policy, EI #2 said she did not. EI #2 explained that EI #4 used unnecessary force which would fall under physical abuse. According to the facility's IN-SERVICE TRAINING RECORD, EI #3, a CNA received Abuse Neglect Misappropriation education on 6/17/2021. During an interview on 8/5/2021 at 8:40 AM, EI #1, the Administrator acknowledged she was the facility's Abuse Coordinator. When asked how she became aware of the incident between RI #1 and EI #4, EI #1 stated on 7/5/2021, it was reported to her by the DON, EI #2, and she and EI #2 both went into the office to talk with EI #3, a CNA. According to EI #1, EI #3 stated EI #4, a CNA, held RI #1's hands to his/her chest, to keep the resident from moving and EI #3 stated, You ain't stronger than me old (man/lady). EI #1 stated the allegation of abuse was substantiated based on the bruising to the resident. EI #1 was asked when did the incident occur. EI #1 replied, according to EI #3 it happened on 7/1/2021. When asked why there was a delay in reporting the incident, EI #1 stated that was a good question. EI #1 stated the CNA, EI #3 indicated to her that she was confused, shocked and not sure what she saw was abuse until after she talked with someone else. EI #1 stated EI #3 had received training on hire on reporting abuse. EI #1 acknowledged that EI #3 did not follow the facility's policy on abuse, when she did not immediately report the allegation of abuse. When asked what the potential harm was for not reporting an allegation of abuse immediately, EI #1 stated the incident could happen again. After reviewing time sheet, EI #1 stated EI #4 worked in the facility on 7/1/2021, 7/3/2021, 7/4/2021 and 7/5/2021 until 9:30 AM. According to the facility's assignment sheet for 7:00 AM to 3:00 PM shift on 7/1/2021, EI #4, a CNA was assigned to care for residents who resided in rooms 309 to 315. During the 7:00 AM to 3:00 PM shift on 7/3/2021, EI #4 was assigned to care for residents who resided in room [ROOM NUMBER] to 316. During the 7:00 AM to 3:00 PM shift on 7/4/2021, EI #4 was assigned to care for residents who resided in room [ROOM NUMBER] to 315. On 7/5/2021 during the 7:00 AM to 3:00 PM shift, EI #4 was assigned to care for residents who resided in room [ROOM NUMBER] to 316. EI #4's time sheet indicated on 7/1/2021, EI #4 clocked in for work at 8:47 AM and clocked out at 3:00 PM. On 7/3/2021, EI #4 clocked in for work at 7:04 AM and clocked out at 3:00 PM. On 7/4/2021, EI #4 clocked in for work at 7:08 AM and clocked out at 3:00 PM. On 7/5/2021, EI #4 clocked in for work at 7:12 AM. The handwritten note on the bottom written by EI #1, the Administrator documented Team member (EI #4) . left at approx. (approximately) 9:30 am (on 7/5/2021). ************************* According to the facility's TIMELINE, the following corrective actions were implemented: . 7/5/2021 - (EI #4) WAS INTERVIEWED AND SUSPENDED IMMEDIATELY AFTER INCIDENT WAS REPORTED. SKIN ASSESSMENT COMPLETED ON (RI #1). 7/6/2021 - INCIDENT INVOLVING (RI #1) WAS DISCUSSED IN DAILY CONNECT MEETING. 7/6 - 7/13/2021 - INVESTIGATION WAS CONDUCTED. 7/14/2021 - FOLLOW-UP WAS SUBMITTED TO ADPH ( Alabama Department of Public Health). CONTACTED (EI #4) TO COME IN AND DISCUSS OUTCOME OF INVESTIGATION. APPT SET FOR 7/16/2021. 7/16/2021 - CNA (EI #4) WAS TERMINATED. 7/16/2021 - PROGRESSIVE DISCIPLINE AND ONE TO ONE TRAINING WITH (EI #3) ON WHAT CONSTITUTES ABUSE AND REPORTING ABUSE PER CMS (Centers for Medicare & Medicaid Services) GUIDELINES WAS COMPLETED. 7/16/2021 - IN-SERVICE TRAINING ON HOW TO CARE FOR (RI #1), INCLUDING INTERVENTIONS AND APPROACHES ON HANDLING AGGRESSIVE BEHAVIORS WAS DONE WITH CNA'S (CNAs) AND NURSES. ************************* After review of the facility's corrective action plan, investigation file, in-service/education records, Quality Assurance plan, and resident and staff interviews, the facility implemented corrective actions from 7/5/2021 to 7/16/2021, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of complaint/report number AL 451.

Based on interviews, review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) did not use Resident Identifier (RI) #3's debit card without the resident's permission for personal use. This deficient practice affected RI #3; one of three sampled residents reviewed for misappropriation of resident's property. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed, Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property . Definitions: . Misappropriation of Resident Property: The deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent . RI #3 was admitted to the facility on [DATE]. RI #3's Quarterly Minimum Data Set with an assessment reference date of 11/11/2020, revealed, the resident was cognitively intact, with a Brief Interview for Mental Status of 15. Facility report titled, Investigation Template dated 02/11/2021 revealed . on 2/4/21 Detective (name) of the (local) Police Department called (EI #3), administrator, to report (EI #4's) fraudulent use of (RI #3's) debit card. He reported (EI #4) used (RI #3's) debit card to make cash transfers to her personal CASH APP account . Transactions were in the month of December, on our (or) about 12/26/2020 - 12/30/2020 . On 06/01/2021 at 5:10 PM, an interview was conducted with RI #3 about the incident. RI #3 stated, that his/her Power of Attorney (POA) called inquiring about funds taken out of the account. RI #3 stated the debit card was missing but it was put back. RI #3 was asked who the person was accused of using the debit card and RI #3 identified EI #4, a CNA. RI #3 was asked if he/she had ever given EI #4 his/her debit card, debit card number or pin number. RI # 3 replied, all that information was written down in a tablet. RI #3 stated, that EI #4 knew where he/she kept tablet. RI #3 was asked where he/she kept debit card. RI #3 pointed to a pouch and stated, that he/she had it in two baskets and the pouch was inside the second basket. When asked if he/she ever gave permission for EI #4 to use debit card, RI #3 stated no. RI #3 was asked how this incident made him/her feel. RI #3 stated, he/she didn't feel good; the resident was sad. On 06/02/2021 at 09:25 AM, a phone interview was conducted with Detective of the local Police Department. The detective stated, EI #4 admitted to being one of RI #3's caregivers and around December she found RI #3's debit card in a tissue box and wrote down the number and used it for cash app transactions. The detective stated there were three to four transactions totaling $500 to EI #4's personal account. The detective stated EI #4 was charged with one count of identity theft and one count of financial exploitation of the elderly 3rd degree. On 06/02/2021 at 2:21 PM, a phone interview was conducted with EI #4, a CNA. EI #4 was asked did she admit to local detective that she use RI #3's debit card without the resident's permission. EI #4 replied, yes. EI #4 was asked would she consider taking a resident's card and using it for personal use abuse. EI #4 stated, yes. When asked what type of abuse, EI #4 replied, misappropriation of property. On 06/04/2021 at 10:59 AM, an interview with EI #1, the Administrator was conducted. EI #1 was asked what measures were put in place after incident. EI #1 replied, the facility interviewed all alert and oriented resident to determine if they had any missing property or misappropriation of funds, all employees were in serviced on abuse to include misappropriation of property in January and February 2021 and resident rights and abuse were discussed in resident council in March 2021. EI #1 was asked did EI #4 follow the facility's policy. EI #1 stated, no, she stole money from a resident. She was arrested, charged and has a case pending. EI #1 was asked would she consider using resident's debit card abuse. EI #1, replied, yes, misappropriation of funds. ************************* Once the allegation of misappropriation was reported to the facility's Administrator, the following corrective actions were implemented EI #4 was placed on suspension. EI #4's employment with the facility was terminated on 02/11/2021. On 02/04/2021, RI #3's sponsor was notified of the allegation of misappropriation and interviewed. On 02/04/2021, the facility initiated an investigation into the allegation of misappropriation; the facility was able to substantiate the allegation of misappropriation On 02/04/2021, the facility reported the allegation of misappropriation to the State Survey Agency On 02/06/2021, all staff were in-serviced on the facility's abuse policy On 02/09/2021 and 02/10/2021, all alert and oriented residents were interviewed to ensure that no one had any misappropriation of property On 03/23 /2021, a Quality Assurance Performance Improvement was meeting held On 03/26/2021, a resident council meeting was held; the facility's abuse policy and procedures to include misappropriation of resident's property were reviewed with all in attendance ************************* After review of the facility's investigation file, in-service/education records, the facility's Quality Assurance plan, staff and resident interviews, the facility implemented corrective actions from 02/04/2021 to 03/26/2021, thus past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 140.

Based on record review, interviews, review of the facility's Visitor Sign In Logs, and review of a facility policy titled, COVID-19 Education, Prevention & Response Guide, the facility failed to ensure Resident Identifier (RI) #1's family was not denied visitation with the resident on 4/28/2021. This affected RI #1; one of three sampled residents reviewed for visitation. Findings include: On 5/28/2021, the State Agency received a complaint alleging facility staff had incorrectly informed RI #1's family upon his/her admission to the facility that the resident would not be allowed visitation with his/her family due to the need to quarantine for 14 days, despite RI #1 and the family being fully vaccinated. Review of a facility policy titled, COVID-19 Education, Prevention & Response Guide, dated 3/2021, revealed, . COVID-19 Considerations for Center Visitations On Wednesday, March 10, 2021 CMS (Centers for Medicare and Medicaid Services) released revisions to Memo QSO-20-39-NH regarding visitation, incorporating vaccine status.Visitation should be person-centered, consider the residents' physical, mental and psychosocial well-being, and support their quality of life. Our centers must facilitate in-person visitation consistent with CMS regulations defined in this guidance. While we continue to recommend adherence to the core principles of COVID-19 infection prevention . we also acknowledge the toll that separation and isolation has taken. We also acknowledge that there is no substitute for physical contact, such as the warm embrace between a resident and their loved one. Therefore, if the resident is fully vaccinated, they can choose to have close contact (including touch) with their visitor . Facilitating Visits, Screening & Documentation of Visitors .Indoor Visits . Centers should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission .Guidance for Admissions . Zone 1 . Zone Description . COVID-19 free/recovered OR fully vaccinated . Patient/Resident Criteria . New admission OR readmission that is fully vaccinated . According to www.data.cms.gov, the facility's county positivity rate for the timeperiod 4/14/2021 to 4/27/2021, indicated the facility's county positivity rate was yellow at 6.4%. RI #1 was admitted to the facility on [DATE]. According to documentation within RI #1's medical record, at the time of his/her admission to the facility, the resident was considered fully vaccinated. A review ofo RI #1's medical record, revealed no orders for the use of Transmission Based Precautions while in the facility. On 6/02/2021 at 2:22 PM, a family member of RI #1 that was present at the facility on the day of admission, was interviewed. This family member said at the time RI #1 was admitted to the facility, RI #1's vaccination card was provided to the facility staff; however the family member said an older gentleman and the lady doing the admission paperwork said RI #1 would have to be quarantined for 14 days. The family member further reported that these facility staff members told him that vaccination status did not matter. The family member said the next day he found out from his aunt he had been given incorrect information, and RI #1 could in fact have visitors. He said when he found that out, he contacted someone at the facility, name unknown, to let them know he would have stayed (instead of driving four hours back home) so he could see RI #1. On 6/04/2021 at 2:03 PM, a follow-up interview was conducted with the family member of RI #1 that was present at the facility on the day of admission. The family member stated he had to wait at the front door during the admission process and was not allowed to come inside. The family member went on to say that one of the first conversations he had with the facility was that RI #1 would have to be quarantined. This family member said because of this, he went ahead and made the four hour drive back home, only to find out the next day that RI #1 could in fact have visitors. When asked who had told the family they could not come into the facility that day, the family member did not know name; the staff were later identified as Employee Identifier (EI) #3, the Interim Administrator. An interview was conducted with EI #3, the Interim Administrator at the time of RI #1's admission, on 6/04/2021 at 3:14 PM. EI #3 was asked why he denied the family of RI #1 access to the building when the resident was admitted . EI #3 answered he may have been confused, but if he did, it was a mistake. EI #3 was asked when family members try to visit with the resident through the admission process, what should be done. EI #3 answered they should be screened and allowed access. A review of the facility's Visitor Sign In Logs revealed RI #1 had no recorded visitors on 4/28/2021. This deficiency was cited as a result of complaint/report number AL 392.

Based on observations, interviews, review of the (YEAR) Food Code and the facility's policy titled Water Temperatures for Dishwashing Machines, the facility failed to ensure dishware was stored to prevent wet nesting and there was space between the 3-compartment sink, the food prep sinks and the facility's plumbing (sewer) system. These deficient practices had the potential to affect all the residents served food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 9/24/2019 indicated the facility had a total of 134 residents and three residents were fed by way of a feeding tube. The facility further failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) did not touch Resident Identifier (RI) #30's toast with her bare hand during the breakfast meal on 9/24/2019. This deficient practice affected one of one resident observed for dining. Findings include: 1) The facility's policy titled Water Temperatures for Dishwashing Machines with an effective date of 7/1/2013, documented . PR[NAME]EDURE . 8. All utensils must be allowed to air dry until surface water has completely disappeared before stacking and storing . On 9/25/2019 at 4:23 PM, seven pans, 20 spoons, 20 knives, and 10 forks were observed to be wet and stacked without space to air dry. In an interview on 9/26/2019 at 9:56 AM, EI #8, the Regional Dietitian was asked, what was the harm of wet-nesting. EI #8 replied, sanitation issues exist because, moist (wet) items have a greater potential to grow bacteria. 2) According to the (YEAR) Food Code, . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During an observation on 9/23/2019 at 3:53 PM, with EI #7, the Dietary Supervisor, no air gap was observed at the 3-compartment sink. EI #7 acknowledged that she did not see a gap in the plumbing of the 3-compartment sink. On 9/24/2019 at 6:00 PM, an observation of the 3-compartment sink was made with EI #8, the Regional Dietitian. EI #8 stated she didn't see an air gap at any of the sinks in the kitchen. In an interview on 9/25/2019 at 4:30 PM, EI #10, the Maintenance Supervisor stated there was a direct connection from the 3-compartment sink and the two food prep sinks to the plumbing. In a follow-up interview on 9/26/2019 at 9:56 AM, EI #8, the Regional Dietitian was asked what the potential harm was when the 3-compartment sink and food prep sinks had a direct connection to the sewer. EI #8 replied, cross contamination and sanitation from the back-up of the drainage from sewer. 3) The facility's policy titled Team Member Sanitary Practices with an effective date of 1/1/2017, documented POLICY It is the policy of this center to promote guidelines for employee sanitary practices. PR[NAME]EDURE For all team members . 5. Use utensils to handle food or wear disposable gloves when necessary to handle food with their hands . RI #30 was admitted to the facility on [DATE]. RI #30's Significant Change in Status Assessment with an assessment reference date of 7/10/2019 indicated the resident required limited assistance of one person for eating. During the breakfast meal observation on 9/24/2019 at 8:11 AM, EI #5, a CNA used her bare left hand to pick up RI #30's toast and spread butter and jelly on the toast. In an interview on 9/24/2019 at 8:20 AM, EI #5, a CNA was asked how she handled RI #30's toast. EI #5 stated she picked it up with her hand and then spread butter and jelly on it. When asked should she touch a resident's food with her bare hands, EI #5 said no. When asked did she touch RI #30's toast with her bare hand, EI #5 said yes. EI #5 was asked what the harm was in touching resident's food with bare hands. EI #5 replied, you do not know if your hands are clean and what you may have touched before touching the food. On 9/25/2019 at 5:41 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked how should staff handle resident's toast if it needed butter and jelly on it. EI #3 replied, either put on a glove or use a utensil. EI #3 was asked when should staff touch a resident's toast with their bare hand. EI #3 replied, never. EI #3 was asked what the harm would be in a CNA touching a resident's piece of toast with their bare hand. EI #3 replied, contaminate their food.

Based on observation, interviews, review of Resident Identifier (RI) #278's medical record, and the facility's policy titled Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA) washed her hands between glove changes during RI #278's provision of incontinence care. This affected RI #278, one of two sampled residents reviewed for bladder and bowel incontinence. Findings include: The facility's policy titled Handwashing/Hand Hygiene with an effective date of 11/1/2017 documented POLICY This center considers hand hygiene the primary means to prevent the spread of infections. POLICY INTERPRETATION AND IMPLEMENTATION . 5. Use alcohol-based hand rub or, alternatively, soap and water for the following situations: . k. After removing gloves; . RI #278 was admitted to the facility on [DATE]. During incontinent care observation on 9/24/2019 at 10:45 AM, EI #6, a CNA removed her soiled gloves and put clean gloves on without washing her hands. EI #6 then removed a towel and secured a clean incontinence brief on RI #278. In an interview on 9/25/2019 at 8:34 AM, EI #6, a CNA was asked what the policy was on washing hands during incontinence care. EI #6 replied, anytime you remove gloves, you should wash your hands. When asked if she washed her hands when she changed gloves, EI #6 said no. On 9/25/2019 at 5:37 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked when should staff wash hands during incontinence care. EI #3 replied, before starting, in between glove changes, after cleaning the front, after cleaning the back, before placing the clean brief and then when finished. EI #3 acknowledged staff should never put on clean gloves without first washing their hands. When asked what the harm would be in not washing your hands when changing gloves during incontinence care, EI #3 stated, the staff could contaminate their hands when they take off gloves that are dirty.

Based on observation, interviews and a review of the facility's policy titled, Medication Administration General Guidelines, the facility failed to ensure a licensed staff member did not leave the medication cart unlocked, unattended and out of the licensed staff member's view. This deficient practice affected one of four medication carts observed during medication administration. Findings include: A review of the facility's policy titled, Medication Administration General Guidelines, with a date of 05/16 revealed the following: . Medication Administration .17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be clearly visible to the personnel administering medications when unlocked . On 06/26/19 at 4:42 p.m., the surveyor observed the medication cart in the hallway unlocked and unattended. The Registered Nurse (RN), Employee Indentifier (EI) #5 was observed inside the dining area talking to residents with her back to the medication cart. On 06/26/19 at 4:42 p.m., the surveyor observed a resident walking on the hallway near the unlocked and unattended medication cart. On 06/26/19 at 5:21 p.m., an interview was conducted with EI #5. The surveyor asked EI #5 how was the medication cart left. EI #5 said she left the medication cart unlocked. The surveyor asked EI #5 how should the medication cart be left when unattended. EI #5 said the medication cart should be locked. The surveyor asked EI #5 what were the concerns with leaving the medication cart unlocked and unattended. EI #5 said someone could get into the cart and take something. On 06/27/19 at 1:40 p.m., an interview was conducted with EI #1, the Director of Nursing (DON). The surveyor asked EI #1 how should the lock on the medication cart be left when unattended. EI #1 said it would depend on how far the cart was out of the nurse's line of site. The surveyor asked EI #1 how should the cart be left when the nurse turned her back to the cart. EI #1 said it should be locked. The surveyor asked EI #1 what were the concerns when the medication cart had been left unlocked and unattended. EI #1 said unauthorized people could get into the medication cart.

Based on observations, interviews, and review of the Maintenance Supervisor's job description titled, DIVERSICARE MANAGEMENT SERVICES POSITION DESCRIPTIONS the facility failed to ensure: (1) there were no water stains on the ceiling tile of Room Locator (RL) #1, (2) the fan was not hanging loosely from the ceiling tile in RL #2, (3) rust was not on the connecting bolts on the front metal frame of the elevated toilet seat, rust was not on the ceiling tile and bathroom wall in RL #3, (4) rust was not on the connecting bolts on the front metal frame of the elevated toilet seat, a water stain was not on the bathroom ceiling tile and another ceiling tile in the bathroom was not torn and peeling in RL#4, (5) the baseboard trim was affixed to the wall on the left side of the air conditioner unit in RL #5, (6) the ceiling tile in RL #6 did not have a hole in it, (7) a water stain was not on the ceiling tile and rust was not on the door frames leading from the bathroom of RL #7, (8) the vent in RL #8 was not hanging loosely from the ceiling, (9) a ceiling tile was not missing, two ceiling tiles were not missing pieces and the baseboard behind the commode in RL #9 was affixed to the wall; and (10) a ceiling tile in RL #10 did not have a water stain on it. These deficient practices affected 11 of 76 residents rooms/bathrooms at the facility. Findings Include: Review of the Maintenance Supervisor's job description titled, DIVERSICARE MANAGEMENT SERVICES POSITION DESCRIPTIONS, without a date, revealed the following: . ACCOUNTABILITY OBJECTIVE: To . direct the overall operation of the maintenance department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe and comfortable condition . KEY RESPONSIBILITIES: 1. Maintenance Functions: . 1. ensures proper maintenance of the facility including carpentry work . equipment . 3. Safety and Sanitation Functions . regularly inspect equipment . to ensure a safe and comfortable environment . On 05/21/19, the State Survey Agency received a complaint which alleged the following: . (RL #9) - Bathroom panel behind the toilet seat is torn and a bathroom ceiling tile is missing. Ombudsman notes this has been an ongoing issue . (RL #8) - Bathroom vent was pulled/coming down out of the ceiling and there is rust on the ceiling. This is identified to be an ongoing issue . (RL #10) - Water spots on the ceiling in the bathroom . (RL #4). Water stains on the ceiling in the bathroom, toilet riser rusted and some of the ceiling fixings are rusted. Ceiling tiles are torn and peeling . (RL #3) - rust observed around ceiling tile and walls in bathroom . (1) On 06/26/19 at 2:14 p.m., the surveyor observed a water stain on the ceiling tile above the bathroom commode in RL #1. On 06/26/19 at 3:08 p.m., during a tour with Employee Indentifer (EI) #4, Maintenance Director, the surveyor asked EI #4 to identify what was on the ceiling tile in RL #1. EI #4 said it was a water stain and they would replace the tile. On 06/27/19 at 10:19 a.m., the surveyor observed no change to the water stained ceiling tile above the commode in RL #1. (2) On 06/26/19 at 2:16 p.m., the surveyor observed the bathroom exhaust fan hanging loosely from the bathroom ceiling in RL #2. On 06/26/19 at 3:10 p.m., the surveyor asked EI #4 to identify what was hanging from the ceiling in RL #2. EI #4 said the fan. EI #4 said it was just a matter of pushing the fan back in. On 06/27/19 at 10:23 a.m., the surveyor observed no changes to the exhaust fan hanging loosely from the bathroom ceiling in RL #2. (3) On 06/26/19 at 2:31 p.m., the surveyor observed rusted connecting bolts on the front metal frame of the elevated toilet and rust was on the bathroom ceiling tile and wall over the commode in RL #3. On 06/26/19 at 3:13 p.m., the surveyor asked EI #4 what was on the connecting bolts of the front metal frame of the elevated toilet seat in RL #3. EI #4 said rust. EI #4 said they would replace the seat because it could cause a skin tear. The surveyor asked EI #4 what was on the ceiling tile and wall above the commode in the bathroom of RL #3. EI #4 said rust. EI #4 said they would replace the ceiling tile and sand and paint the wall area. On 06/27/19 at 10:28 a.m. the surveyor observed there was no changes to the bathroom ceiling tile or wall in RL #3. (4) On 06/26/19 at 2:14 p.m., the surveyor observed rusted connecting bolts on the front metal frame of the elevated toilet seat, water stain on the ceiling tile above the bathroom commode and another bathroom ceiling tile was torn and peeling in RL #4. On 06/26/19 at 2:57 p.m., the surveyor asked EI #4 what was on the connecting bolts on the front metal frame of the elevated toilet seat, ceiling tile above the bathroom commode and the second bathroom ceiling tile of RL #4. EI #4 said it was the same thing; rust and a water stain. On 06/27/19 at 10:30 a.m. the surveyor observed no changes to the water stain on the ceiling tile above the bathroom commode and another bathroom ceiling tile that was torn and peeling in RL #4. (5) On 06/26/19 at 2:23 p.m., the surveyor observed the baseboard trim was loose from the wall on the left side of the air conditioner unit in RL #5. After the above observation, the surveyor asked EI #4 what was that (pointing to the baseboard tile). EI #4 said the tile was loose. EI #4 said they would replace the baseboard tile. On 06/27/19 at10:36 a.m., the surveyor observed no changes to the loose baseboard trim. The surveyor also observed rusty connecting bolts on the front metal frame of the elevated toilet seat in RL #5. On 06/27/19 at 3:20 p.m., EI #4 said eight elevated toilet seats had been ordered. (6) On 06/26/19 at 2:25 p.m., the surveyor observed a hole in the ceiling tile above the left side of the bed in RL #6. On 06/26/19 at 3:05 p.m., the surveyor asked EI #4 what was on the tile in RL #6. EI #4 said a hole. EI #4 said they would replace the tile. On 06/27/19 at 10:39 a.m., the surveyor observed no changes to the ceiling tile with the hole in RL #6. (7) On 06/26/19 at 1:55 p.m., the surveyor observed a water stain on the ceiling tile above the commode and rust on the door frame entrance to the bathroom of RL #7. On 06/26/19 at 3:16 p.m. the surveyor asked EI #4 what was on the ceiling tile above the commode in RL #7. EI #4 said a water stain. EI #4 said they would replace the ceiling tile. The surveyor asked EI #4 what was on the door frame entrance into the bathroom of RL #7. EI #4 said rust. The surveyor asked EI #4 what could be done to repair the bathroom door frame. EI #4 said they would need to sand the door frame and paint it. (8) On 6/26/19 at 3:35 p.m., the surveyor observed the vent in RL #8 coming loose from the ceiling. On 06/27/19 at 9:04 a.m., the vent in RL #8 remained in the same position. On 06/27/19 at 10:31 a.m., the surveyor conducted an interview with EI #4. When asked to describe what he saw in the ceiling of RL #8, EI #4 said the vent needed to be pushed back up in the ceiling. (9) On 06/26/19 at 3:20 p.m., the surveyor observed one tile missing from the ceiling. The tile was observed leaning against the wall next to the sink. Two tiles in the ceiling had torn pieces and the baseboard behind the commode was coming loose from the wall in RL #9. On 06/27/19 at 9:00 a.m., the observations in RL #9 remained the same. On 06/27/19 at 10:34 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 what did he observe in RL #9. EI #4 said a missing tile in the ceiling, two ceiling tiles that needed to be replaced, and a loose baseboard that needed to be replaced. (10) On 06/26/19 at 4:14 p.m., the surveyor observed a water stain on the tile in RL #10. On 06/27/19 at 9:22 a.m., the water stain remained on the ceiling tile. On 06/27/19 at 10:27 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 how would he describe the spot on the ceiling tile. EI #4 said it was a water stain. The surveyor asked EI #4 should the ceiling tiles be stained with water. EI #4 said no. On 06/27/17 at 10:08 a.m., before the surveyor and EI #4 went to observe RL #8, #9 and #10, the surveyor asked EI #4 would missing tiles in the ceiling, water stains on tiles in the ceiling, baseboards coming loose from the wall and vents detaching from the ceiling be a part of a homelike environment, EI #4 said no. This deficiency was written as the result of the investigation of complaint/report number AL 336.

Based on interviews, record review and review of a facility policy titled, Notification of Change in Patient/Resident Health Status, the facility failed to provide evidence Resident Identifier (RI) #1's sponsor/family was notified when RI #1's [MEDICATION NAME] 0.25 mg (milligrams) was changed from 8:00 a.m. to 8:00 p.m. This deficient practice affected RI #1, one of five residents sampled for medications being administered improperly. Findings Include: Review of a facility policy titled, Notification of Change in Patient/Resident Health Status, dated 06/17, revealed the following: . Process The center will consult the resident's . patient representative when there is: . (C) A need to alter treatment . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #1's (MONTH) 2019 Active Orders (Physician Orders) revealed RI #1 was receiving [MEDICATION NAME] 0.25 mg by mouth once a day. RI #1's physician's orders [REDACTED]. Change [MEDICATION NAME] Administration time to q (every) 8 pm. This order was written by Employee Identifier (EI) #2, The Assistant Director of Nursing (ADON). On 06/25/19 at 4:11 p.m., the surveyor conducted an interview with RI #1's sponsor. When asked if the facility had corrected the administration time for RI #1's [MEDICATION NAME], RI #1's sponsor said not that she knew of. RI #1's sponsor said she had not been notified of a change. RI #1's sponsor said she had been told the time had not been changed. On 06/27/19 at 11:26 a.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Assistant Director of Nursing (ADON). EI #2 said she did not recall why, but she saw where she wrote an order for [REDACTED].#2 looked at RI #1's nurses notes and said she did not see a note where the family had been notified of the change. On 06/27/19 at 1:30 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing (DON). EI #1 said RI #1's [MEDICATION NAME] order was changed to 8:00 p.m. on 02/12/19. The surveyor asked EI #1 did he notify RI #1's family of the change. RI #1 said he did not recall notifying the family. When asked where would there be evidence that RI #1's family had been notified of the change in time, EI #1 said in the nurses notes. EI #1 looked at RI #1's nurses notes and said he did not see where the family had been notified. This deficiency was written as the result of the investigation of complaint/report number AL 195.

Based on observations, interviews and review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the facility failed to ensure the DAILY NURSE STAFFING FORM reflected the census on two of three days of the survey. This deficient practice had the potential to affect all 131 residents residing in the facility. Findings Include: A review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form revealed there were 131 residents residing in the facility during the survey. On 06/26/19 at 8:15 a.m., the surveyor observed the DAILY NURSE STAFFING FORM was posted for the morning shift (7 a.m. - 3 p.m.). The census was missing from the form. On 06/26/19 at 5:00 p.m., the surveyor observed the DAILY NURSE STAFFING FORM was posted for the evening shift (3 p.m. - 11 p.m.). The census was missing from the form. 06/27/19 at 7:35 a.m., the surveyor observed the DAILY NURSE STAFFING FORM was posted for the morning shift. The census was missing from the form. On 06/27/19 at 1:30 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing (DON). The surveyor asked EI #1 who was responsible for posting the DAILY NURSE STAFFING FORM . EI #1 said EI #6, the Work Force Manager/Central Supply Clerk. The surveyor asked EI #1 what information should be on the DAILY NURSE STAFFING FORM. EI #1 said the census, the number of RNs (Registered Nurses), LPNs (Licensed Practical Nurses),CNAs (Certified Nursing Assistants), the date and the name of the facility. The surveyor asked EI #1 what information was missing from the DAILY NURSE STAFFING FORM dated 06/26/19 and 06/27/19 . EI #1 said the census. On 06/27/19 at 3:12 p.m., the surveyor conducted an interview with EI #6, the staff member responsible for posting the DAILY NURSE STAFFING FORM. The surveyor asked EI #6, looking at the DAILY NURSE STAFFING FORM dated 06/26/19 and 06/27/19, what information was missing from the form. EI #6 said the census. When asked why she thought the census was not placed on the forms, EI #6 said she probably overlooked it. The surveyor asked EI #6 what was the rationale for having the census on the form. EI #6 said so anyone looking at the form could tell how many residents were in the facility.

Based interview and review of the Diversicare of Foley - QAPI CENTER PLAN, the facility's Quality Assessment and Assurance committee failed to review the reported allegations of physical abuse and develop a corrective action plan to prevent recurrence. On 4/28/2018, Resident Identifier (RI) #49 was observed to willfully pushed RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. Refer to F600 This deficient practice affected RI #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining 26 residents who reside on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Quality Assurance and Performance Improvement, F867. Findings include: The Diversicare of Foley - QAPI CENTER PLAN dated 4/17/2018, documented Quality Assurance and Performance Improvement (QAPI) . QAPI Guiding Purpose: QAPI is a data-driven, responsive and proactive process for the purposes of evaluating indicators of the outcomes of care, quality of life and service with a focus on improvement within our center. QAPI involves team members at all levels of the organization and the activities include the following: *Identify opportunities for improvement; *Address gaps in systems or processes; *Develop and implement an improvement or corrective plan; And continuously monitor the effectiveness of our interventions . The facility provided the State Survey Agency with their Quality Assurance and Performance Improvement (QAPI) Meeting for 3/27/2018, 4/17/2018, 5/15/2018, 6/19/2018 and 7/17/2018. A review of these meeting notes indicated the facility did not discuss the repeated incidents of resident/resident abuse that took place on the secure Alzheimer's Care Unit (Dementia unit). In an interview on 7/31/2018 at 1:04 PM, EI #2, the Director of Nursing Service (DNS) was asked if the allegations of abuse were reviewed by the facility's Quality Assurance committee for the detection of trends/patterns, EI #2 said no. When asked why not, EI #2 said the committee talked about the incidents as falls and not allegations of abuse. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented QA: Impromptu/Ad-hoc QAPI meeting led by Regional Vice Presidents (Robin Jones, Brooke Sims) and Sr Director of Clinical Operations (Brenda Barton) held 8/02/2018 with Facility Administrative staff, ACU Programming Manager, Administrator, and Medical Director (via telephone) to discuss findings from survey, completing investigations for concerns, and to review resident to resident altercations occurring on the Dementia unit. Committee to address adverse event monitoring and resident to resident altercations; including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events and resident to resident altercations in the facility, and how the facility will use the data to develop activities to prevent incidents. Plan is to re-convene to identify/ determine root cause of the identified deficient practices. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F867 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795

Based on interviews and review of the facility's Abuse Policy, the facility failed to investigate allegations of abuse perpetrated by Resident Identifier (RI) #49 and RI #84, two cognitively impaired residents who reside on the facility's secure Alzheimer's Care Unit. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. This deficient practice affected RI #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F610. Findings include: Investigation The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Investigation Anytime there is an allegation of abuse, . the center must report the alleged violation to the Administrator/Director of Nursing, the Chief Compliance Officer, and other officials, and also initiate an immediate investigation and prevent further potential abuse. Based on the investigation findings, the center will implement corrective actions to prevent recurrence. All investigations shall be conducted by the Administrator/Director of Nursing or subject matter expert unless there is a conflict of interest or they are implicated in the alleged violations. In the event an alleged violation occurs when none of these people are available, the manager in charge is responsible for initiating the investigation procedure unless there is a conflict of interest or the person is implicated in the alleged violations. The investigation shall include interviews of team members, visitors, resident/patients, volunteers and vendors who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions, speculation or conclusions. Written statements from involved parties should not be requested as all information will be documented on the investigation form or a state required form. The documentation of the investigation shall be kept in a secure administrative file . The medical record should be reviewed to determine resident/patient's past history and condition and its relevance to the alleged violation. Federal law requires the center to have evidence of investigations of alleged violations. The investigation form or state required form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law . Corrective Action The center shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident/patient or other resident/patients that may be affected. The Director of Nursing in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken should be documented. Documentation All alleged violations shall be recorded. Copies of this form shall be kept in the center. Documentation in the medical record shall be made where necessary for continuity of care for the resident/patient. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law. Refer to F600 In an interview with EI #2, the DNS on 7/31/2018 at 1:04 PM, to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). When asked in there was an investigation into the allegation of abuse that occurred on 4/28/2018 between RI #49 and RI #71, EI #2 said no. When asked if there was an investigation into the allegation of abuse that occurred on 5/2/2018 between RI #49 and RI #85, EI #2 said she did not investigate it. EI #2 was asked if there was an investigation done into the allegation of abuse that occurred on 5/9/2018 between RI #71 and RI #84. EI #2 replied, she did not have a documented investigation. When asked if there was investigation into the allegation of abuse that occurred on 5/25/2018 between RI #49 and RI #85, EI #2 said no. When asked if there was an investigation into the allegation of abuse that occurred on 5/25/2018 between RI #49 and RI #71, EI #2 no. When asked why not, EI #2 said she was out of town and just did not do it. EI #2 stated she just didn't do what she was supposed to do and took full responsibility for it. EI #2 was asked if there was an investigation into the allegation of abuse that occurred between RI #49 and RI #85 on 6/26/2018. EI #2 answered no and explained she should have started an investigation immediately after being made aware of the incident. During an interview on 7/31/2018 at 3:35 PM, EI #1, the Administrator stated they were not in the formal investigative mode when they discovered these situations, so nothing was written down about them. When asked what an investigation into potential abuse should consist of, EI #1 said an investigation consisted of understanding the facts about what happened to accurately determine effective ways to prevent reoccurrences. EI #1 said witnesses should be interviewed, an observation of the area may be needed, and a review of the medical records. When asked why these allegations of abuse were not investigated, as specified in the facility's Abuse Policy, EI #1 said he didn't know. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Investigation: The investigations of above reported allegations are currently on-going and will be completed within the required time frame to the state agency. Reviewed/Revised care plans for identified RIs to include interventions to reduce/eliminate risk of resident to resident altercations/abuse by 8/02/2018 by Registered Nurses. All center staff provided group in-service education by the Sr Director of Clinical Operations regarding Facility Abuse Policy to include definitions of Abuse, Examples of Abuse, and Interventions to deal with aggressive and/or catastrophic reactions of resident/patients to include one to one monitoring to ensure resident protection and prevention of subsequent altercations and what to report and when. Implementation of the abuse policy to include identification and reporting of Abuse as well as Investigating Abuse. Inclusion of the interpretive guidelines for resident to resident altercations began 8/02/2018 at 1:00PM and will continue until all staff have received training. One hundred twelve of 128 staff members trained on as of 8/03/2018. Additional trainings scheduled for 8/4/2018 to in-service weekend staff working and PRN staff, facility has no agency staff. No staff member will be allowed to work without the required training after 8/04/2018. Training for staff who will be completing/ documenting/ tracking incidents. All investigation files will be maintained in the Interim Administrator's office. VP will oversee and review the investigation process and reporting via the company Red event reporting program. Red event reporting occurs when an event (abuse) has been identified, it is reported to the VP as a Red event and is reviewed on a conference call weekly with COO and VP of Clinical Operations. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F610 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interview and review of the Regional Vice President's job description, the facility's governing body failed to provide monitoring and oversight to ensure the facility's abuse policy and procedure was implemented. This deficient practice affected Resident Identifier (RI) #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F837. Findings include: DIVERSICARE JOB DESCRIPTION for the Regional Vice President, EI #16, dated (MONTH) (YEAR), documented . GENERAL PURPOSE Directs and oversees the 24/7 day to day operations of the Diversicare post-acute care centers ESSENTIAL JOB DUTIES . Ensures compliance with State and Federal Regulations . Leads an effective Quality Assurance and Process Improvement (QAPI) Program for the region and ensures all centers have an effective program . Supports, provides guidance and manages the administrators . Refer to F600, F 607, F609, F610, F740, F835, F838 and F867 In an interview on 8/2/2018 at 9:15 AM, EI #16, the Vice President of Operations (VPO) was asked who was the facility's governing body. EI #16 replied, the Director of Nursing Service, the Administrator, the Chief Operating Officer and herself. When asked as a member of the governing body, what oversight did she provide to the facility. EI #16 stated she conducted onsite visits of the facility on a quarterly basis. When asked how was the frequency determined, EI #16 stated it depended on the need of the facility. EI #16 was asked if she was aware of the chart audit conducted in (MONTH) (2018) by the Director of Clinical Operations, EI #3, and the DNS, EI #2. EI #16 replied, no. When asked if she should have been informed of the results of the chart audit, EI #16 said yes. EI #16 explained she should have been aware because it would have been an issue with respect to abuse allegations. EI #16 stated had she been informed of the results of the chart audit, she would have made sure the facility followed the policy and regulations. EI #16 was asked if she had any direct involvement in the facility's Quality Assurance and Performance Improvement committee. EI #16 replied that if she was present in the facility on the day of the meeting, she would attend. In a follow-up interview on 8/2/2018 at 2:34 PM, EI #16, the VPO acknowledged that she was the Administrator's direct supervisor. When asked how she provided oversight to the Administrator, EI #16 said by way of weekly mass calls with all 21 centers for updates. EI #16 stated one-to-one calls were generally done every week and sometimes every other week. When asked what type of things were discussed, EI #16 said some weeks quality issues were discussed, general operations, team member engagement, stewardship and customer satisfaction. When asked if she had knowledge of any of the concerns identified by the State survey agency, EI #16 said no. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Governing Body failed to intervene and direct staff on actions after identifying potential abuse: VP will act as the governing body presence in the center until compliance has been achieved to ensure that the facility has an active governing body that is responsible for establishing and implementing policies regarding the management of the facility to include the full implementation of the Abuse Policy and Procedures. VP will be overseeing the RVP to ensure implementation of the facility policy and procedure until compliance achieved. Daily phone conferences will be conducted 5 days a week for 4 weeks to apprise the VP of happenings in the center as well as any red events. Schedule has been developed for on-site visits. The Administrator and DNS have been placed on Administrative leave pending investigation. An interim administrator started on 08/03/2018. Interim Administrator was trained on abuse policies/regulations by Sr Director of Clinical Operations on 08/03/2018. The Sr Director of Clinical Operations assumed the Interim DNS role on 08/03/2018. Both will serve as the Abuse coordinators for the center. Abuse Coordinators Names and Phone numbers are posted throughout the facility for staff reporting. The company has retained the services of an independent consultant on 08/04/2018 to follow up on the effectiveness of the training and provide additional training as needed. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F837 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interviews and review of job description's, the facility administrative staff, to include Employee Identifier (EI) #1, the facility's Administrator, who is responsible for directing and overseeing the day to day operations of the facility and EI #2, the Director of Nursing Service (DNS), who manages the nursing department, failed to identify incidents of resident/resident altercations as abuse. They also failed to implement the facility's abuse policy and procedure and failed to ensure they educated the staff on the correct definition of abuse. These deficient practices affected Resident Identifier (RI) #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: The undated job description for EI #2, the Director of Nursing Service, documented . ACCOUNTABILITY OBJECTIVE Manages the Department of Nursing in accordance with policy and procedure, state and federal regulations to promote high quality care and service to the facility and community . KEY RESPONSIBILITIES . 1. Implements policies/procedures with follow-up and supervision of staff to ensure compliance . Refer to F600, F607, F609, F610, F740, and F838 In a telephone interview with EI #4, a Licensed Practical Nurse (LPN) on 7/24/2018 at 9:40 AM, she referenced a text message sent to her by EI #2, which stated be careful of how you chart so that she (EI #2) didn't have to report incidents as abuse. EI #10 supplied the State survey agency with the text to EI #4 from EI #2, which read Careful how you chart so I don't have to turn it in as abuse . Only chart in general notes no more behavior notes that way we don't draw attention to ourselves. I'll call you in a few and let you know what's going on. In an interview on 7/25/2018 at 9:43 AM, EI #8, a Certified Nursing Assistant (CNA) was asked what was she instructed to do and document when a resident exhibited behaviors. EI #8 stated she was told to not tell the nurse anything because hitting and pushing was not abuse because it was probably not the resident's intention. When asked who gave her those instructions, EI #8 said EI #1, the Administrator; EI #2, the DNS; and EI #15, the Assistant DNS. EI #8 stated these instructions were given during the first of (MONTH) (2018). During an interview with EI #9, a CNA on 7/25/2018 at 2:59 PM, she stated the staff had a meeting the other day with EI #1, the Administrator and EI #15, the Assistant DNS in which they were told not to use common sense. According to EI #9, the administrator had a piece of paper and he stated if they saw a resident hit or push another resident, that may not be what they really saw; that they would get together and talk about it. During an interview with EI #19, a CNA, on 7/27/2018 at 9:40 AM, stated the staff was told that what they saw, as it relates to residents' behaviors/abuse, was not really what they saw. When asked when was she told this, EI #19 stated she told this on Monday by EI #1, the Administrator. In an interview on 7/30/2018 at 10:48 AM, EI #4, a LPN was asked if she considered the incidents that occurred on 4/28/2018 and 5/25/2018 when RI #49 willfully pushed RI #71 down, causing the resident to fall as abuse. EI #4 said yes. When asked if she reported to EI #2 that the incidents were abuse, EI #4 said no. EI #4 explained that the nursing staff was not supposed to tell the administrative staff whether or not it was abuse. They were tell them what happened and they (administrative staff) would make the determination whether or not it was abuse. During an interview with EI #10, a RN on 7/30/2018 at 12:32 PM, she stated she was told by EI #2, the DNS and EI #15, the Assistant Director of Nursing Service (ADNS) that it was not abuse if it was not malicious. EI #10 further stated that now since the State survey agency was in the facility, the facility has said it's abuse whether or not there was an intent to cause harm. In a telephone interview on 7/30/2018 at 4:11 PM, EI #5, a LPN was asked to describe what she observed between RI #49 and RI #85 on 5/2/2018. EI #5 stated RI #85 was attempting to crawl up in a chair and RI #49 slapped RI #85. When asked to describe the slap, EI #5 stated RI #49 held (his/her) arm up, bent the elbow, rotated the arm and slapped RI #85. When asked to define abuse, EI #5 said it was would someone intentionally or willfully intended to cause harm to someone. According to EI #5, she thought this incident was abuse, but after talking with the DNS (EI #2) and EI #3, the Director of Clinical Operations (DCO), they advised her otherwise. EI #5 said they told her it appeared not to be a slap but more of a tap on the face. EI #5 stated she was told she should have used different wording in her charting (documentation). During an interview on 7/30/2018 at 7:51 AM, EI #2, the DNS, stated for the last [AGE] years the facility did not have to report resident on resident altercations involving dementia patients. EI #2 stated she was aware of the regulatory changes that occurred in (MONTH) (2017), but said the changes had not sunk in with her yet. During a follow-up interview on 7/31/2018 at 1:04 PM, EI #2, the DNS acknowledged she had asked the nursing staff to call her before they documented a resident's fall to ensure the staff was documenting objectively. EI #2 stated there was a lot of subjective documentation. When asked why the staff stated they had to communicate with you before documenting, to ensure the documentation avoided looking as though it was abuse, EI #2 said she didn't know why the staff would say that. EI #2 explained that she was confused about the facility's abuse policy and she didn't know. EI #2 stated she just wanted to the staff to document what they saw and not what they felt. After review of the facility's policy, EI #2 stated she now knows each of the six resident-on-resident altercations should have been considered allegations of abuse. When asked if the allegations of abuse were reviewed by the facility's Quality Assurance committee for the detection of trends/patterns, EI #2 said no. When asked why not, EI #2 said the committee talked about the incidents as falls and not allegations of abuse. In another interview with EI #2, the DNS on 8/1/2018 at 10:22 AM, she was asked what had staff been told about resident-on-resident abuse. EI #2 replied, she thought the facility missed that. EI #2 stated the facility focused more on exploitation rather than residents with dementia now being considered abuse. EI #2 explained she felt this is where she failed because she didn't not stress that topic. EI #2 stated that part of the policy was not engrained in her thinking until a conference call in (MONTH) (2018). The job description for EI #1, the Administrator dated (MONTH) (YEAR), documented . Accountability Objective Directs, oversees and manages the 24/7 day to day operations of the Diversicare post-acute care center . Key Responsibilities . Serve as the center abuse coordinator. Strives to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting Ensures compliance with State and Federal Regulations . Leads an effective Quality Assurance and Process Improvement (QAPI) Program . In an interview with the facility's Administrator, EI #1, on 7/31/2018 at 3:53 PM, he was asked about the resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #1 explained that he didn't understand those were allegations of abuse. EI #1 stated before the change in (MONTH) (2017), there was more latitude to say whether something was intentionally done or not. EI #1 stated they were not in the formal investigative mode when they discovered those situations, so nothing was written down about them. When asked what an investigation into potential abuse should consist of, EI #1 said an investigation consisted of understanding the facts about what happened to accurately determine effective ways to prevent reoccurrences. EI #1 said witnesses should be interviewed, an observation of the area may be needed, and a review of the medical records. When asked why the facility's Abuse Policy was not implemented when these six resident-on-resident altercations occurred, EI #1 said he didn't know. EI #1 was asked why the staff felt as though they were trained that what they saw was not what really what they saw. EI #1 explained he informed the staff to not let their emotions get in the way of their documentation. EI #1 stated some of the documentation (charting) seemed to be exaggerated and the staff had documented objectively not subjectively. EI #1 stated maybe the staffs' assumptions led them to say what they saw was not really what they saw. When asked who would know better what they saw, EI #1 replied, the staff who saw it. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Administration Administrator/Abuse Coordinator has reported all of the above mentioned allegations to the state agency and full investigations are ongoing to be completed within 5 days to the state agency. Administrator received in-service education by the Sr. DCO regarding the Facility Abuse policy, Abuse identification and reporting on 8/02/2018. Administrator and DNS were placed on administrative leave pending full investigation on 8/02/2018. Interim Administrator in place on 8/03/2018 and Sr Director of Clinical Operations assumed role of interim DNS effective 8/02/2018. The interim administrator started on 08/03/2018. She was trained on abuse policies/regulations by Sr Director of Clinical Operations on 08/03/2018. VP will oversee the full implementation of Abuse policy. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interview and review of Resident Identifier (RI) #49's medical record, the facility failed to identify and address the behavioral health care needs of RI #49, a resident with repeated incidents of resident/resident abuse . On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. Refer to F600 The facility further failed to ensure there was a policy/procedure/protocol that directed the staff on how to respond to behaviors and track and trend behaviors to ensure the resident's behavioral care plan was effective in meeting the needs of the resident. RI #49 had documented escalating behaviors; however, the staff responsible for behavior management, Employee Identifier (EI) #12, the Unit Manager/Memory Care Director, was not aware of any systems the facility had in place to monitor RI #49's behaviors. This deficient practice affected RI #49, one of 11 sampled residents reviewed for behaviors, and placed this resident in immediate jeopardy for serious injury, harm or death. This deficient practice had the potential to affect all 20 residents identified by the facility as having behavioral health needs. On 8/2/2018 at 5:08 PM, the facility's Regional Vice President was notified of the findings of immediate jeopardy in the area of Behavioral Health Services, F740. Findings include: RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49 has a medical history to include [DIAGNOSES REDACTED]. RI #49's Admission Minimum Data Set (MDS) with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #49's care plan titled Sometimes I show behavior symptoms/risks Becoming confused/cursing/pushing at staff and others, confrontational behavior and (of) lower cognitive residents . I also mimic the behavior of some of the lower cognitive residents initiated on 4/27/2018 and last revised on 6/22/2018, had a goal of Episodes of (my mimicking lower cognitive residents, and pushing staff and others), pushing, pulling on others, . will not interfere with the safety or well-being of myself or others thru my next review. The interventions listed were: During episodes of inappropriate behaviors, please re-direct me by approaching slowly and speaking to me in a calm and steady voice - trying to redirect me to an alternative activity or topic of discussion. Encourage me to participate in activities to give me something to focus on. Help me avoid situations and people that trigger inappropriate behaviors. Help me maintain a consistent daily routine. Notify my doctor if my behaviors interfere with my functioning and give meds as ordered. Offer me a quieter setting to help soothe me. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. Refer to F600 RI #49's behavior charting for the time period 4/1/2018 to 4/30/2018, indicated on 4/21/2018, RI #49 had threatening behavior; on 4/28/2018 RI #49 was pushing; and on 4/30/2018, RI #49 had abusive language. RI #49's behavior charting for the time period 5/1/2018 to 5/31/2018, indicated RI #49 displayed threatening behaviors on 5/2/2018, 5/3/2018, 5/19/2018, 5/20/2018, 5/23/2018 and 5/25/2018. RI #49 displayed pushing behaviors on 5/4/2018, 5/20/2018, 5/23/2018 and 5/25/2018. RI #49 was kicking/hitting on 5/5/2018, 5/18/2018, 5/20/2018, 5/21/2018, and 5/25/2018. RI #49 had three instances of grabbing, on 5/5/2018, 5/19/2018 and 5/20/2018. RI #49 used abusive language on 5/5/2018, 5/18/2018 and 5/25/2018. RI #49's behavior charting for the time period 6/1/2018 to 6/30/2018, indicated RI #49 displayed threatening behaviors on 6/8/2018, 6/9/2018, 6/14/2018, 6/17/2018, 6/22/2018, 6/24/2018 and 6/27/2018. RI #49 was pushing on 6/20/2018, 6/22/2018 and 6/26/2018. RI #49 was kicking/hitting on 6/8/2018, 6/19/2018, 6/22/2018, 6/24/2018 and 6/26/2018. RI #49 had one instance of grabbing on 6/24/2018. RI #49 used abusive language on 6/8/2018, 6/9/2018 and 6/26/2018. RI #49 had one instance of pinching/scratching/spitting on 6/22/2018. RI #49's behavior charting for the time period 7/1/2018 to 7/31/2018, indicated RI #49 had one instance of pushing on 7/5/2018 and one instance of threatening behavior on 7/26/2018. RI #49 was kicking/hitting on 7/5/2018, 7/10/218, 7/11/2018, 7/12/2018, 7/17/2018, 7/21/2018 and 7/28/2018. On 8/2/2018 at 9:00 AM , EI #2, the Director of Nursing Services (DNS) stated EI #12, the Unit Manager/Memory Care Director was responsible for overseeing behavior management on the facility's Alzheimer's Care Unit (ACU). In an interview on 8/2/2018 at 10:45 AM, EI #12, the Unit Manager/Memory Care Director, was asked how was behavior management addressed on the ACU. EI #12 stated there was not a truly focused program the facility was utilizing. When asked if the facility had a policy/procedure or protocol for behavior management, EI #12 said no. EI #12 was asked what system she utilized to track resident behaviors in an attempt to implement prevention techniques. EI #12 replied, there was not a system. EI #12 was asked, what behaviors RI #49 displayed on admission. EI #12 replied, RI #49 was exit seeking, so a wanderguard was placed. EI #12 acknowledged RI #49's behavior care plan was initiated on 4/27/2018. When asked what was done after RI #49 forcefully pushed another resident down on 4/28/2018, EI #12 said she didn't see anything that was done. When asked what was done after RI #49 was observed to slap another resident on 5/2/2018, EI #12 said the residents were separated and redirected. EI #12 commented I failed that situation, I really did my best. EI #12 explained that she had never reviewed RI #49's behavior charting. EI #12 said if she would have reviewed the behavior charting, it would have allowed her to see the information with the day and time, trends, who was working with the resident, etc When asked what was done after RI #49 yelled and physically assaulted RI #85 on 5/25/2018, EI #12 said she was not sure as she was on vacation. EI #12 commented, the resident's care plan was revised on 6/22/2018 with an intervention to notify the physician of behaviors that interfere with functioning, give medications as ordered and take resident to a quieter setting. When asked about RI #49's behaviors for the month of June, EI #12 said RI #49's behaviors were escalating. EI #12 then said the incidents involving RI #49 could have possibly been avoided and behaviors could have been decreased if RI #49's behaviors had been tracked. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Behavior Management: Facility failed to have policy and procedure to instruct staff response on how to track and trend behaviors Facility RN reviewed and updated the behavior care plan for RI #49 on 08/02/2018. Other identified RIs care plans will be reviewed and updated by RN by 08/02/2018. Training for Dementia unit staff to be provided by Sr Director of Clinical Operations regarding updating care plans when incidents occur. Training to utilize Dementia Care Policy/ Guideline that includes proactive philosophies to enhance calm environment and minimize distressing behavioral expressions, education on Relias regarding managing of challenging behaviors, general approaches for those with dementia to understand behaviors and provide a safe environment. Post behavioral event tool will be used to determine root cause and is designed to understand the trigger of the behavior exhibited to assist with establishing appropriate interventions. Sr Director of Clinical Operations provided in-service education for all staff members beginning 8/3/2018 at 7:00AM on Dementia Care Guideline that includes proactive philosophies to enhance calm environment and minimize distressing behavioral expressions, General approaches for those with dementia to understand behaviors and provide a safe environment and the post behavioral event tool designed to understand the root cause or trigger of the behavior exhibited to help with establishing the correct intervention. Sr Director of Clinical Operations has completed 47 of 128 team members and has scheduled additional trainings on 8/4/2018 to educate the PRN and weekend staff. No other staff will work after 8/4/2018 until they have received the training. Clinical team members, includes: Interim Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Education, Unit Managers, will complete the post behavioral event tool during the daily clinical meeting for residents with documented behaviors to determine possible root cause of exhibited behaviors which contributed to the incident occurrence. Clinical team will then update care plan to address results of possible root cause beginning 8/4/2018. Interim Administrator will attend meetings with the clinical team to assure compliance. Impromptu in-servicing, small group discussion, increased oversight by management team (new ACU Programming Manager), collaboration of line staff in program development as well as implementation, more family involvement to individualize programs and plans of care for residents residing on the Dementia unit. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F740 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interviews and review of the CENTER ASSESSMENT TOOL, the facility failed to address the care and services, as well as staff competencies, necessary to provide care to the residents who reside on the 35-bed secured Alzheimer's Care Unit. This deficient practice affected all 28 residents who reside on the secured Alzheimer's Care Unit and placed these residents in immediate jeopardy for serious injury, harm or death. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F838. Findings include: Diversicare of Foley's CENTER ASSESSMENT TOOL dated 10/31/2017 and reviewed with the QAA/QAPI committee on 11/20/2017, revealed the facility treated residents with [DIAGNOSES REDACTED]. The assessment tool did not indicate the facility had a secure 35-bed Alzheimer's Care Unit. During an interview on 7/31/2018 at 1:04 PM, Employee Identifier (EI) #2, the Director of Nursing Services (DNS) was asked what involvement she had in the facility's assessment. EI #2 said, she, the Administrator, the Assistant DNS and others sat down as a team awhile back to look at the assessment. When asked how the facility's assessment addressed the facility's secured Alzheimer's Care Unit. EI #2 reviewed the assessment and said she didn't see where the facility's assessment addressed the Alzheimer's Care Unit. EI #2 was then asked why it would be important to include the facility's Alzheimer's Care Unit in the facility's assessment. EI #2 said to determine what services the facility provided and staff competencies needed, to ensure the facility was able to provide the best care. In an interview on 7/31/2018 at 3:53 PM, EI #1, the Administrator was asked how the facility's assessment addressed the facility's secured Alzheimer's Care Unit. EI #1 replied, it listed the [DIAGNOSES REDACTED]. When asked if the facility's assessment indicated the facility had a secured Alzheimer's Care Unit, EI #1 said it did not. When asked why not, EI #1 said he felt he covered it in the assessment by listing the diagnoses. EI #1 was asked how the facility's assessment addressed the staff competencies needed to care for the resident's on the Alzheimer's Care Unit. EI #1 said regardless of whether it's written in the assessment, it did not affect whether the facility did dementia training. When asked if the facility's assessment addressed the Alzheimer's Care Unit, EI #1 again stated he felt like it did because it listed [DIAGNOSES REDACTED]. EI #1 was asked who all was involved in the development of the facility's assessment. EI #1 replied, it was a group meeting with the leadership managers. EI #1 explained the list of names on the front page of the assessment were those involved. Diversicare of Foley's CENTER ASSESSMENT TOOL dated 10/31/2017 and reviewed with the QAA/QAPI committee on 11/20/2017, indicated the person involved in completing assessment as: EI #1, the Administrator; EI #2, the DNS; EI #16, the Regional Vice President; EI #17, the Medical Director; EI #15, the Assistant DNS; and EI #18, the Social Worker. In an interview on 8/2/2018 at 9:00 AM, EI #16, the Vice President of Operations was asked had she seen the facility's assessment. EI #16 said she worked on it awhile back, before it became regulatory. When asked if the facility's assessment should address the dementia unit (Alzheimer's Care Unit), EI #16 said whether it be by population or mentioning the ACU directly, yes it should encompass the memory care unit (dementia unit). ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Facility Assessment failed to assure services to provide care to residents residing on the Dementia care unit were addressed: Facility Assessment was revised by the Quality Assurance Committee on 08/02/2018 to include a 35 bed Dementia (Memory Care) unit. Wellness Solutions was added as a service. Impromptu in-servicing, small group discussion, increased oversight by management team (new ACU Programming Manager), collaboration of line staff in program development as well as implementation, more family involvement to individualize programs and plans of care for residents residing on the Dementia unit. After completing investigation into the abuse allegations, the QA committee will schedule another meeting to follow up on the investigative findings as well as the implementation of the corrective action plan addressing the ACU. During this follow up meeting, the QA committee will discuss root cause and make any further revisions to the facility assessment as indicated. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F838 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interviews and review of the facility's Abuse Policy, the Director of Nursing Service (DNS) failed to report allegations of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, these allegations of abuse were not reported to the State survey agency. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. This deficient practice affected RI #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F609. Findings include: The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Reporting All alleged violations involving mistreatment, neglect, abuse or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Immediately means as soon as possible: 1. Any allegation of abuse within two hours and 2. Any neglect, mistreatment, exploitation or misappropriation of resident property without serious injury within 24 hours The results of all investigations must be reported by the Administrator/Director of Nursing to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . Refer to F600 An interview was conducted with EI #2, the DNS, on 7/31/2018 at 1:04 PM to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #2 was asked when did she become aware that RI #49 willfully pushed RI #71 down on 4/28/2018. EI #2 stated she didn't recall being made aware of this incident. When it was explained to EI #2 that EI #4, LPN, stated she notified her within 30 minutes of the occurrence, EI #2 stated she certainly believed EI #4, she just didn't recall being notified. EI #2 stated she considered the occurrence abuse and should have reported it. When asked if she reported the allegation of abuse to the Administrator, EI #2 said no. EI #2 was asked when did she become aware that RI #49 had slapped RI #85 on 5/2/2018. EI #2 stated she was not notified of this. EI #2 explained that she discovered this incident during a chart review. When asked if the allegation of abuse was reported, EI #2 said no. EI #2 explained that she should have reported it but didn't. EI #2 was asked when she became aware that RI #84 forcefully and intentionally pushed RI #71 causing the resident to be rendered unconscious on 5/9/2018. EI #2 answered that she was immediately notified of the incident by the nurse, EI #10. When asked if the incident met the definition of abuse, EI #2 said yes. When asked if the allegation of abuse was reported to the Administrator and State survey agency, EI #2 said no. EI #2 was asked when she became aware of the incident that occurred on 5/25/2018 when RI #49 yelled at RI #85, pushed RI #85's head into a wall and tried to slam a door on RI #85. EI #2 replied, she was immediately notified. When asked was the incident considered an allegation of abuse, EI #2 said yes. When asked if she reported to the Administrator this allegation of abuse, EI #2 said she did not recall. EI #2 was asked when she became aware of the incident that occurred on 5/25/2018 when RI #49 forcefully pushed RI #71 down causing the resident to fall. EI #2 replied that she was notified later the night of 5/25/2018. When asked what this incident considered abuse, EI #2 said yes. EI #2 explained that she did not report this allegation of abuse to the Administrator or the State survey agency; EI #2 stated she was out of town. Lastly, EI #2 was asked when she became aware of the incident that occurred on 6/26/2018 when RI #49 and RI #85 were pushing each other and fell . EI #2 replied, she was pretty sure she was made aware right when it happened. When asked if considered this occurrence abuse, EI #2 said yes. When asked if the allegation of abuse was reported, EI #2 said no. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Reporting: All center staff provided group in-service education by the Sr Director of Clinical Operations regarding Facility Abuse Policy to include definitions of Abuse, Examples of Abuse, and Interventions to deal with aggressive and/or catastrophic reactions of resident/patients to include one to one monitoring to ensure resident protection and prevention of subsequent altercations and what to report and when. Implementation of the abuse policy to include identification and reporting of Abuse as well as Investigating Abuse. Inclusion of the interpretive guidelines for resident to resident altercations began 8/02/2018 at 1:00PM and will continue until all staff have received training. One hundred thirty-five staff members trained on as of 8/04/2018. Facility has no agency staff. No staff member will be allowed to work without the required training after 8/04/2018. All identified allegations reported to state agency beginning on 7/29/2018. On 08/04/2018, Sr Director of Clinical Operations and Director of Nursing Services reviewed records (Nurses notes, behavioral notes, weekly notes, daily notes) over the past 30 days to determine if other incidents occurred that should have been reported. Any instances of abuse identified, Interim Administrator will follow and implement reporting per facility policy and procedure. The interim administrator started on 08/03/2018. She was trained on abuse policies/regulations by Sr Director of Clinical Operations on 08/03/2018. The Sr Director of Clinical Operations assumed the DNS role on 08/03/2018. Both will serve as the Abuse coordinators for the center. Abuse Coordinators Names and Phone numbers are posted throughout the facility. Sr Director of Clinical Operations will provide clinical oversight and monitoring of the reporting process. The Administrator received in-service education by the Sr Director of Clinical Operations on 8/02/2018 at 8:00AM. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F609 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interviews, medical record review and the facility's Abuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure the Director of Nursing Service (DNS) reported allegations of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, these allegations of abuse were not reported to the State survey agency (Reporting); 3) ensure the DNS and Administrator identified situations of resident/resident altercations as abuse (Identification); 4) protect Resident Identifier (RI) #71, RI #85 and other residents from abuse perpetrated by RI #49 and RI #84 (Protection); and 5) investigate these allegations of physical abuse (Investigation). On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. These deficient practices affected Resident Identifier (RI) #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: Prevention The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Prevention Team members are required to report incidents of suspected abuse, neglect or misappropriation of resident/patient property without fear of reprisal . The Administrator/Director of Nursing shall identify, intervene and correct situations in which abuse, neglect or misappropriation of resident/patient property are more likely to occur . Refer to F600 An interview was conducted with EI #2, the Director of Nursing Service (DNS), on 7/31/2018 at 1:04 PM to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #2 was asked what actions did the facility take to prevent further abuse after RI #49 willfully push RI #71 down on 4/28/2018. EI #2 replied, she didn't know what was done. When asked what corrective actions the facility took after the abuse that occurred on 5/2/2018 when RI #49 slapped RI #85. EI #2 stated there were no change in interventions to prevent another incident. EI #2 was asked what actions the facility took after RI #84 forcefully and intentionally pushed RI #71 down, rendering RI #71 unconscious on 5/9/2018. EI #2 replied, an assessment of RI #71 to include neurological checks were performed on RI #71 because the resident was either difficult to arouse or unconscious and the physician and family were notified. When asked what corrective actions the facility took after RI #49 yelled at RI #85, pushed RI #85's head into a wall and tried to slam a door on the resident on 5/25/2018, EI #2 said she redirected RI #49 and called the physician to restart RI #49's [MEDICATION NAME] medication. According to Mosby's (YEAR) Nursing Drug Reference with a copyright date of (YEAR), [MEDICATION NAME] is an anticonvulsant medication used to treat various types of [MEDICAL CONDITION] disorders. [MEDICATION NAME] can also be used to treat manic episodes related to [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]) and to prevent migraine headaches. EI #2 was asked what corrective actions/steps were taken to prevent further abuse after RI #49 forcefully pushed RI #71 down causing RI #71 to fall on 5/25/2018. EI #2 explained, if she had it to do all over again, she would follow the facility's policy. EI #2 stated she didn't do what she should have known to do and took full responsibility for it; no corrective actions were taken. When asked what actions were taken after it was observed RI #49 and RI #85 were pushing each other and both residents fell on [DATE], EI #2 replied other than looking at both residents to make sure they were okay, she did not know what was done. Reporting The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Reporting All alleged violations involving mistreatment, neglect, abuse or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Immediately means as soon as possible: 1. Any allegation of abuse within two hours and 2. Any neglect, mistreatment, exploitation or misappropriation of resident property without serious injury within 24 hours The results of all investigations must be reported by the Administrator/Director of Nursing to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . Refer to F600 An interview was conducted with EI #2, the DNS, on 7/31/2018 at 1:04 PM to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #2 was asked when did she become aware that RI #49 willfully pushed RI #71 down on 4/28/2018. EI #2 stated she didn't recall being made aware of this incident. When it was explained to EI #2 that EI #4, LPN, stated she notified her within 30 minutes of the occurrence, EI #2 stated she certainly believed EI #4, she just didn't recall being notified. EI #2 stated she considered the occurrence abuse and should have reported it. When asked if she reported the allegation of abuse to the Administrator, EI #2 said no. EI #2 was asked when did she become aware that RI #49 had slapped RI #85 on 5/2/2018. EI #2 stated she was not notified of this. EI #2 explained that she discovered this incident during a chart review. When asked if the allegation of abuse was reported, EI #2 said no. EI #2 explained that she should have reported it but didn't. EI #2 was asked when she became aware that RI #84 forcefully and intentionally pushed RI #71 causing the resident to be rendered unconscious on 5/9/2018. EI #2 answered that she was immediately notified of the incident by the nurse, EI #10. When asked if the incident met the definition of abuse, EI #2 said yes. When asked if the allegation of abuse was reported to the Administrator and State survey agency, EI #2 said no. EI #2 was asked when she became aware of the incident that occurred on 5/25/2018 when RI #49 yelled at RI #85, pushed RI #85's head into a wall and tried to slam a door on RI #85. EI #2 replied, she was immediately notified. When asked was the incident considered an allegation of abuse, EI #2 said yes. When asked if she reported to the Administrator this allegation of abuse, EI #2 said she did not recall. EI #2 was asked when she became aware of the incident that occurred on 5/25/2018 when RI #49 forcefully pushed RI #71 down causing the resident to fall. EI #2 replied that she was notified later the night of 5/25/2018. When asked was this incident considered abuse, EI #2 said yes. EI #2 explained that she did not report this allegation of abuse to the Administrator or the State survey agency; EI #2 stated she was out of town. Lastly, EI #2 was asked when she became aware of the incident that occurred on 6/26/2018 when RI #49 and RI #85 were pushing each other and fell . EI #2 replied, she was pretty sure she was made aware right when it happened. When asked if considered this occurrence abuse, EI #2 said yes. When asked if the allegation of abuse was reported, EI #2 said no. Identification The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Definitions Abuse means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Physical abuse includes hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment . Identification Incidents of alleged violations shall be reviewed by QAPI (Quality Assurance Process Improvement) for detection of patterns or trends . Refer to F600 During an interview on 7/30/2018 at 7:51 AM, EI #2, the DNS, stated for the last [AGE] years the facility did not have to report resident on resident altercations involving dementia patients. EI #2 stated she was aware of the regulatory changes that occurred in (MONTH) (2017), but said the changes had not sunk in with her yet. In an interview on 7/30/2018 at 10:48 AM, EI #4, a LPN was asked if she considered the incidents that occurred on 4/28/2018 and 5/25/2018 when RI #49 willfully pushed RI #71 down, causing the resident to fall as abuse. EI #4 said yes. When asked if she reported to EI #2 that the incidents were abuse, EI #4 said no. EI #2 explained that the nursing staff was not supposed to tell the administrative staff whether or not it was abuse. They were tell them what happened and they (administrative staff) would make the determination whether or not it was abuse. During an interview with EI #10, a RN on 7/30/2018 at 12:32 PM, she stated she was told by EI #2, the DNS and EI #15, the Assistant Director of Nursing Service (ADNS) that it was not abuse if it was not malicious. EI #10 further stated that now since the State survey agency was in the facility, the facility has said it's abuse whether or not there was an intent to cause harm. In a telephone interview on 7/30/2018 at 4:11 PM, EI #5, a LPN was asked to describe what she observed between RI #49 and RI #85 on 5/2/2018. EI #5 stated RI #85 was attempting to crawl up in a chair and RI #49 slapped RI #85. When asked to describe the slap, EI #5 stated RI #49 held his/her arm up, bent the elbow, rotated the arm and slapped RI #85. When asked to define abuse, EI #5 said it was when someone intentionally or willfully intended to cause harm to someone. According to EI #5, she thought this incident was abuse, but after talking with the DNS (EI #2) and EI #3, the Director of Clinical Operations (DCO), they advised her otherwise. EI #5 said they told her it appeared not to be a slap but more of a tap on the face. EI #5 stated she was told she should have used different wording in her charting (documentation). During a follow-up interview on 7/31/2018 at 1:04 PM, EI #2, the DNS acknowledged she had asked the nursing staff to call her before they documented a resident's fall to ensure the staff was documenting objectively. EI #2 stated there was a lot of subjective documentation. When asked why the staff stated they had to communicate with you before documenting, to ensure the documentation avoided looking as though it was abuse, EI #2 said she didn't know why the staff would say that. EI #2 explained that she was confused about the facility's abuse policy and she didn't know. EI #2 stated she just wanted the staff to document what they saw and not what they felt. After review of the facility's policy, EI #2 stated she now knows each of the six resident-on-resident altercations should have been considered allegations of abuse. When asked if the allegations of abuse were reviewed by the facility's Quality Assurance committee for the detection of trends/patterns, EI #2 said no. When asked why not, EI #2 said the committee talked about the incidents as falls and not allegations of abuse. In an interview with the facility's Administrator, EI #1, on 7/31/2018 at 3:53 PM, he was asked about the resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #1 explained that he didn't understand those were allegations of abuse. EI #1 stated before the change in (MONTH) (2017), there was more latitude to say whether something was intentionally done or not. In another interview with EI #2, the DNS on 8/1/2018 at 10:22 AM, she was asked what had staff been told about resident-on-resident abuse. EI #2 replied, she thought the facility missed that. EI #2 stated the facility focused more on exploitation rather than residents with dementia now being considered abuse. EI #2 explained she felt this is where she failed because she didn't stress that topic. EI #2 stated that part of the policy was not engrained in her thinking. Protection The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Protection If the circumstances require it, Administrator/Director of Nursing or designee shall remove a resident/patient suspected of being the subject of an alleged violation to an environment where the resident/patient's safety can be protected. * If the suspected perpetrator is another resident/patient, the Administrator/Director of Nursing or designee shall separate the resident/patients so they do not have access to each other until the circumstances of the alleged incident can be determined . RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission Minimum Data Set (MDS) with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85 face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71, down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. Refer to F600 On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. Refer to F600 An interview was conducted with EI #2, the DNS, on 7/31/2018 at 1:04 PM to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). EI #2 was asked what actions did the facility take to protect RI #71 and other residents after RI #49 willfully pushed RI #71 down on 4/28/2018. EI #2 replied, she didn't know what was done. When asked what was done to protect RI #85 and other residents after the abuse that occurred on 5/2/2018 when RI #49 slapped RI #85. EI #2 stated there was nothing done. EI #2 was asked how the facility protected RI #71 and other residents after RI #84 forcefully and intentionally pushed RI #71 down, rendering RI #71 unconscious on 5/9/2018. EI #2 replied, an assessment of RI #71 to include neurological checks were performed on RI #71 because the resident was either difficult to arouse or unconscious and the physician and family were notified. When asked how the facility protected RI #85 and other residents after RI #49 yelled at RI #85, pushed RI #85's head into a wall and tried to slam a door on the resident on 5/25/2018, EI #2 said she redirected RI #49 and called the physician to restart RI #49's [MEDICATION NAME] medication. EI #2 was asked how the facility protected RI #71 and other residents after RI #49 forcefully pushed RI #71 down causing RI #71 to fall on 5/25/2018. EI #2 explained, if she had it to do all over again, she would follow the facility's policy. EI #2 stated she didn't do what she should have known to do and took full responsibility for it; no corrective actions were taken. When asked how the facility protected other residents after it was observed RI #49 and RI #85 were pushing each other and both residents fell on [DATE], EI #2 replied other than looking at both residents to make sure they were okay, she did not know what was done. Investigation The facility's Abuse Policy with a effective date of (MONTH) (YEAR), documented . Investigation Anytime there is an allegation of abuse, . the center must report the alleged violation to the Administrator/Director of Nursing, the Chief Compliance Officer, and other officials, and also initiate an immediate investigation and prevent further potential abuse. Based on the investigation findings, the center will implement corrective actions to prevent recurrence. All investigations shall be conducted by the Administrator/Director of Nursing or subject matter expert unless there is a conflict of interest or they are implicated in the alleged violations. In the event an alleged violation occurs when none of these people are available, the manager in charge is responsible for initiating the investigation procedure unless there is a conflict of interest or the person is implicated in the alleged violations. The investigation shall include interviews of team members, visitors, resident/patients, volunteers and vendors who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions, speculation or conclusions. Written statements from involved parties should not be requested as all information will be documented on the investigation form or a state required form. The documentation of the investigation shall be kept in a secure administrative file . The medical record should be reviewed to determine resident/patient's past history and condition and its relevance to the alleged violation. Federal law requires the center to have evidence of investigations of alleged violations. The investigation form or state required form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law . Corrective Action The center shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident/patient or other resident/patients that may be affected. The Director of Nursing in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken should be documented. Documentation All alleged violations shall be recorded. Copies of this form shall be kept in the center. Documentation in the medical record shall be made where necessary for continuity of care for the resident/patient. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law. Refer to F600 In an interview with EI #2, the DNS on 7/31/2018 at 1:04 PM, to discuss the six resident-on-resident altercations that occurred on the facility's Alzheimer's Care Unit (ACU). When asked in there was an investigation into the allegation of abuse that occurred on 4/28/2018 between RI #49 and RI #71, EI #2 said no. When asked if there was an investigation into the allegation of abuse that occurred on 5/2/2018 between RI #49 and RI #85, EI #2 said she did not investigate it. EI #2 was asked if there was an investigation done into the allegation of abuse that occurred on 5/9/2018 between RI #71 and RI #84. EI #2 replied, she did not have a documented investigation. When asked if there was investigation into the allegation of abuse that occurred on 5/25/2018 between RI #49 and RI #85, EI #2 said no. When asked if there was an investigation into the allegation of abuse that occurred on 5/25/2018 between RI #49 and RI #71, EI #2 no. When asked why not, EI #2 said she was out of town and just did not do it. EI #2 stated she just didn't do what she was supposed to do and took full responsibility for it. EI #2 was asked if there was an investigation into the allegation of abuse that occurred between RI #49 and RI #85 on 6/26/2018. EI #2 answered no and explained she should have started an investigation immediately after being made aware of the incident. During an interview on 7/31/2018 at 3:35 PM, EI #1, the Administrator stated they were not in the formal investigative mode when they discovered these situations, so nothing was written down about them. When asked what an investigation into potential abuse should consist of, EI #1 said an investigation consisted of understanding the facts about what happened to accurately determine effective ways to prevent reoccurrences. EI #1 said witnesses should be interviewed, an observation of the area may be needed, and a review of the medical records. When asked why these allegations of abuse were not investigated, as specified in the facility's Abuse Policy, EI #1 said he didn't know. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Implementation -- Failure of the Facility to follow the center Abuse Policy . Director of Clinical Education reviewed documentation to ensure all team members have completed Annual abuse training by 8/02/2018. All center staff provided group in-service education by the Sr Director of Clinical Operations regarding Facility Abuse Policy to include definitions of Abuse, Examples of Abuse, and Interventions to deal with aggressive and/or catastrophic reactions of resident/patients to include one to one monitoring to ensure resident protection and prevention of subsequent altercations and what to report and when. Implementation of the abuse policy to include identification and reporting of Abuse as well as Investigating Abuse. Inclusion of the interpretive guidelines for resident to resident altercations began 8/02/2018 at 1:00PM and will continue until all staff have received training. One hundred twelve of 128 staff members trained on as of 8/03/2018. Additional trainings scheduled for 8/4/2018 to in-service weekend staff working and PRN staff, facility has no agency staff. No staff member will be allowed to work without the required training after 8/04/2018. In-service education regarding Abuse identification and reporting to include the Interpretive Guidelines for resident to resident abuse of any type provided to the Administrator and DNS by the Sr Director of Clinical Operations on 8/02/2018 at 8:00AM. Training included Resident to Resident altercations involving residents with Dementia. Interim Administrator received abuse training by the Sr Director of Clinical Operations on 08/03/2018. All of the above referenced allegations have been reported to the state agency by the Administrator/Abuse Coordinator as of 8/02/2018. All investigations shall be conducted by the Interim Administrator/Director of Nursing. The above referenced allegations with the complete investigation of occurrences will be submitted to the state survey agency within the required 5 days of the report. The Administrator and DNS have been placed on Administrative leave pending investigation. The interim administrator started on 08/03/2018. She was trained on abuse policies/regulations by Sr Director of Clinical Operations on 08/03/2018. The Sr Director of Clinical Operations assumed the DNS role on 08/03/2018. Both will serve as the Abuse coordinators for the center. Abuse Coordinator Name and Phone numbers posted throughout the facility. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

Based on interviews, review of a complaint received by the Alabama State Survey Agency, the facility's Abuse Policy and medical record reviews, the facility failed to ensure Resident Identifier (RI) #71 and RI #85 were free from abuse perpetrated by RI #49 and RI #84, residents who reside on the secured Alzheimer's Care Unit (Dementia unit) of the facility. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71, down causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. On 5/9/2018, RI #84 was observed by staff to forcefully and intentionally push RI #71 down to the floor, which rendered RI #71 unconscious. These deficient practices affected RI #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: On 7/18/2018, the Alabama State Survey Agency received a complaint, in which the caller reported resident on resident altercations on the dementia unit. The caller alleged, RI #84 pushed RI #71 and RI #85 down. The dates and specific information was not known by the caller. Then on 5/25/2018, RI #49 followed another resident into their room and pushed the resident's head into the wall. The facility's Abuse Policy with an effective date of (MONTH) (YEAR), documented . Definitions Abuse means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, punching and kicking . POLICY STATEMENT It is the policy of the center to take appropriate steps to prevent the occurrence of abuse . 1) RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission Minimum Data Set (MDS) with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #71 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #71's Quarterly MDS with an assessment reference date of 4/19/18, indicated RI #71 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #71 displayed physical behavioral symptoms directed toward others during this assessment period. RI #71's Progress Notes dated 4/28/2018 at 6:44 PM written by Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN) documented . (RI #71) was standing in hallway at porch area in front of (another resident) rollator and (another resident) was saying get get out of here . (RI #49) got up and pushed this Resident (RI #71) down. (RI #71) landed in sitting position and scraped (his/her) side of (his/her) back . (RI #71) sitting on floor crying with back against chair/rollator - abrasion noted to upper left side of back . In a telephone interview on 7/30/2018 at 10:48 AM, EI #4, a LPN acknowledged she witnessed the incident when RI #49 pushed RI #71 down on 4/28/2018. EI #4 stated she was standing at the medication cart and there was about four to five residents in a semi-circle in the porch area and RI #49 was standing. As RI #71 walked into the middle of the semi-circle, RI #49 forcefully pushed RI #71 to get the resident out of the group; RI #71 fell to the floor. According to EI #4, RI #49 didn't intend to make RI #71 fall but RI #49 did intentionally push RI #71. When asked if she considered this incident abuse, EI #4 said yes. In an interview on 7/31/2018 at 1:04 PM, EI #2, the DNS was asked to define abuse. EI #2 defined abuse as the willful act of confinement, causing harm, pain, or mental anguish. EI #2 further explained that willful meant the action was deliberate, but did not necessarily mean there was an intent to cause harm or injury. When asked if it would be considered abuse, if a staff member witnessed one resident push another resident down, EI #2 said yes. During an interview on 7/31/2018 at 3:53 PM, EI #1, the Administrator, acknowledged the incident that occurred on 4/28/2018, when RI #49 pushed RI #71 down, should have been considered as abuse. 2) RI #85 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #85's Admission MDS with an assessment reference date of 4/6/2018, indicated RI #85 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #85 displayed wandering behavior daily during this assessment period and the wandering significantly intruded on the privacy of the activities of others. RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission MDS with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #49's Progress Notes titled Behavior Charting dated 5/2/2018 at 11:21 PM, written by EI #5, a LPN, documented Describe Behavior/Mood: Resident (RI #49) sitting in chair on porch area when lower cognitive Resident (RI #85) entered porch area and began to try and attempt to climb into the chair beside (RI #49). (RI #49) began yelling at resident Go away Just go away. The other resident (RI #85) continued to climb up in chair . CNA (Certified Nursing Assistant) (EI #6) was in the process of entering porch area to attempt to redirect resident that was climbing in chair out of area when the higher functioning resident (RI #49) slapped the lower functioning resident (RI #85) in the face . In a telephone interview on 7/30/2018 at 4:11 PM, EI #5, a LPN was asked to describe what she observed between RI #49 and RI #85 on 5/2/2018. EI #5 stated RI #85 was attempting to crawl up in a chair and RI #49 slapped RI #85. When asked to describe the slap, EI #5 stated RI #49 held his/her arm up, bent the elbow, rotated the arm and slapped RI #85. EI #5 stated she assessed RI #85 and did not see any redness. According to EI #5, she thought this incident was abuse, but after talking with the DNS (EI #2) and EI #3, the Director of Clinical Operations (DCO), they advised her otherwise. EI #5 said they told her it appeared not to be a slap but more of a tap on the face. EI #5 stated she was told she should have used different wording in her charting (documentation). EI #5 acknowledged that she did not report this incident to the Administrator or DNS. During an interview on 7/31/2018 at 1:04 PM, EI #2, the DNS stated she was not called about the incident that occurred between RI #49 and RI #85 on 5/2/2018. EI #2 stated she discovered the documentation during a chart review. EI #2 acknowledged the incident should have been handled as an allegation of abuse. During an interview on 7/31/2018 at 3:53 PM, EI #1, the Administrator, acknowledged a resident slapping another resident met the definition of physical abuse. 3) RI #84 was readmitted to the facility on [DATE]. RI #84 has a medical history to include [DIAGNOSES REDACTED]. RI #84's Quarterly MDS with an assessment reference date of 4/6/2018, indicated RI #84 was severely impaired in cognitive function with a Brief Interview for Mental Status (BIMS) of five. RI #71 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #71's Quarterly MDS with an assessment reference date of 4/19/18, indicated RI #71 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #71 displayed physical behavioral symptoms directed toward others during this assessment period. RI #71's Progress Notes dated 5/9/2018 at 4:00 PM, written by EI #10, a Registered Nurse (RN), indicate on 5/9/2018, RI #71 fell and was momentarily unconscious after the fall. The progress noted indicated RI #71 had a hematoma on left forehead. In a telephone interview on 7/30/2018 at 12:32 PM, EI #10, a RN, was asked about the 5/9/2018 incident. When asked what she witnessed, EI #10 said she only saw a hand and half of a forearm. She said when she got to RI #71 after the fall, RI #84 was standing over RI #71. EI #10 said the hand and arm she saw appeared to be that of RI #84, based on the shape of the hand and the fingernails. EI #10 said she saw the hand of RI #84 forcefully make contact with RI #71's chest, close to the shoulder. EI #10 said it was forceful. During an interview on 7/31/2018 at 1:04 PM, EI #2, the DNS acknowledged she became aware of the 5/9/2018 incident immediately after it had occurred. When asked how she became aware, EI #2 stated she thought EI #10 reported it to her. When asked what was said, EI #2 said she was told RI #84 had caused RI #71 to fall and hit (his/her) head. When asked what caused the fall, EI #2 said she was told the residents were on the porch and RI #84 pushed RI #71 in an attempt to move RI #71 away from RI #84. EI #2 was asked if this action met the definition of abuse. EI #2 replied, yes it did. In an interview on 7/31/2018 at 3:53 PM, EI #1, the Administrator, agreed the incident that occurred on 5/9/2018 between RI #71 and RI #84 was a situation of potential abuse. 4) RI #85 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #85's Admission MDS with an assessment reference date of 4/6/2018, indicated RI #85 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #85 displayed wandering behavior daily during this assessment period and the wandering significantly intruded on the privacy of the activities of others. RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission MDS with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #49's Progress Notes titled Behavior Charting dated 5/25/2018 1:48 PM, written by EI #7, a LPN, documented . Describe Behavior/Mood: Agitation. Restlessness. Aggression noted towards lower cognitive Residents What was the resident doing prior to or at the time of behavior/mood: CNA (EI #8) reported this Resident pushed (RI #85's) face into wall. Staff attempted to separate Residents. This Resident (RI #49) continues to target (RI #85). (RI #85) wanders in an area, (RI #49) will yell at other Resident (RI #85) and attempt to push, slap, and hit (RI #85) . In an interview on 7/25/2018 at 9:43 AM, EI #8, a CNA was asked to describe the incident that occurred on 5/25/2018 between RI #49 and RI #85. EI #8 said she was exiting the dining room with EI #9, another CNA, when she saw RI #85 standing in the doorway of the bathroom across the hall. RI #49 then went up to RI #85 and punched RI #85 twice in the back, then took RI #85 by the back of the head and slammed RI #85's face into the metal door facing. EI #8 said as she and EI #7 were approaching the residents, RI #49 slammed the bathroom door on RI #85. In an interview on 7/25/2018 at 2:59 PM, EI #9, a CNA was asked to describe the incident that occurred on 5/25/2018 between RI #49 and RI #85. EI #9 said she saw RI #49 hit RI #85 in the back twice, and described RI #49 as angry at the time of the altercation. EI #9 said this incident occurred in RI #49's room, at the bathroom doorway. RI #49 then pushed RI #85's face into the door facing, and when RI #85 stumbled into the bathroom, RI #49 slammed the door on RI #85. In a telephone interview on 7/30/2018 at 11:28 PM, EI #7, a LPN was asked about the incident that occurred on 5/25/2018 between RI #49 and RI #85. According to EI #7, she was notified of the incident by EI #8, a CNA. EI #8 reported that RI #49 had yelled at RI #85, pushed RI #85's head into the wall and tried to close the door on RI #85. EI #7 said after she completed a body audit of RI #85, she went down the hall in an attempt to find either the DNS, EI #2 or the Administrator, EI #1. EI #7 stated she found EI #2, the DNS and asked her to come to the Dementia unit because there was a problem. According to EI #7, she reported to EI #2, that she had been told by EI #8 (CNA) who was present to witness the notification, that RI #49 had yelled at RI #85, pushed RI #85's head into the wall and tried to slam a door on RI #85. EI #7 stated when EI #2 came to the Dementia unit, she completed a body audit of RI #85 and re-oriented RI #49. When asked if abuse was discussed, EI #7 said no. When asked to define abuse, EI #7 stated there were several different forms of abuse. Physical abuse was a form and it included hitting, kicking, pushing, slapping and punching. When asked if she considered this incident between RI #49 and RI #85 as abusive, EI #7 said yes. During an interview on 7/31/2018 at 1:04 PM, EI #2, the DNS acknowledged the incident that occurred on 5/25/2018 between RI #49 and RI #85 was abuse. In an interview on 7/31/2018 at 3:53 PM, EI #1, the Administrator, agreed the incident involving RI #49 and RI #85 that occurred on 5/25/2018 was an incident of potential abuse and should have been investigated by the facility as such. 5) RI #71 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #71's Quarterly MDS with an assessment reference date of 4/19/18, indicated RI #71 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #71 displayed physical behavioral symptoms directed toward others during this assessment period. RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission MDS with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #49's Progress Notes dated 5/25/2018 at 7:28 PM, written by EI #4, a LPN, documented . Resident (RI #49) in another Resident's room (number) and (RI #71) was ambulating down hallway and started to enter room (number) and this Resident (RI #49) started pushing Resident (RI #71) back resulting in (RI #71) falling in doorway . (RI #49) has dementia with behavior disturbances - (RI #49) easily agitated and wanders in unit going in other Residents room taking their belongings - Hx (history) of aggressive behavior since admission with staff unable to redirect . Resident alert with confusion - aggravated and angry at this moment - yelling at staff and other Resident's around. and slapping at this nurse making contact multiple times . An interview was conducted with EI #4, a LPN on 7/30/2018 at 10:48 AM. EI #4 was asked about the incident that occurred on 5/25/2018 when RI #49 pushed RI #71 down causing RI #71 to fall. EI #4 said she was walking down the hall to take another resident their medication. EI #4 said she saw RI #71 at the end of the hallway but then RI #71 turned around and started to go into a resident's room. EI #4 said she then heard RI #49 say, get out of here then she witnessed RI #49 forcefully push RI #71 down. EI #4 stated she was within three feet of the residents when the incident occurred. EI #4 further stated RI #49 was supposed to be on one-to-one staff supervision at this time, due to an incident that occurred earlier in the day, but no staff was present with RI #49 when RI #49 forcefully pushed RI #71 down to the floor. When asked if this altercation between RI #49 and RI #71 was abuse, EI #4 said yes. Both EI #2, the DNS and EI #1, the Administrator stated in interviews on 7/31/2018 at 1:04 PM and 7/31/2018 at 3:53 PM respectively, stated the altercation between RI #49 and RI #71 that occurred on 5/25/2018 was abuse. 6) RI #85 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #85's Admission MDS with an assessment reference date of 4/6/2018, indicated RI #85 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #85 displayed wandering behavior daily during this assessment period and the wandering significantly intruded on the privacy of the activities of others. RI #49 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #49's Admission MDS with an assessment reference date of 4/25/2018, indicated RI #49 was severely impaired in cognitive skills for daily decision making, with long and short term memory problems. According to this MDS, RI #49 displayed inattention, delusions, physical behavioral symptoms directed toward others, rejection of care and wandering during this assessment period. RI #49's Progress Notes dated 6/26/2018 at 2:30 PM, written by EI #10, a RN, documented . This resident (RI #49) and another resident (RI #85) were pushing each other and both fell . This was witnessed and (RI #49) landed in a sitting position. (RI #49) did not hit (his/her) head . During an interview on 7/30/2018 at 12:32 PM, EI #10, a RN was asked about the progress note dated 6/26/2018. EI #10 stated she was in the office when one of the CNAs came and told her that two residents were on the floor. EI #10 stated she went down to the sensory room and observed RI #49 and RI #85 on the floor, with EI #11, the Physical Therapist (PT) present. According to EI #10, EI #11 stated she was working with another resident when RI #49 came in and sat near her. Then RI #85 came and put (his/her) hand on RI #49's arm. The residents then started to push each other and fell to the floor. When asked if she considered this abuse, EI #10 said no based on what she had been told by the facility but now she would say it was abuse because pushing, hitting and kicking was abuse. In an interview on 7/31/2018 at 8:31 AM, EI #11, the PT was asked about the incident that occurred between RI #49 and RI #85 on 6/26/2018. EI #11 said the incident occurred in the sensory room on the ACU. EI #11 said she had taken another resident into the sensory room to complete an evaluation and RI #49 followed them into the room and sat down. EI #11 said RI #85 also came into the room, waked over to RI #49 and then pushed RI #49 in the upper arm. EI #11 further explained RI #85's hand was open, and the force of the push/nudge moved RI #49's upper body. She said this appeared to irritate RI #49 and RI #49 turned and shoved RI #85 the same way. EI #11 said both residents began shoving each other back and forth, and before she could get to them both RI #49 and RI #85 fell to the floor. EI #11 said she would consider the altercation she witnessed to be abuse. Both EI #2, the DNS and EI #1, the Administrator stated in interviews on 7/31/2018 at 1:04 PM and 7/31/2018 at 3:53 PM respectively, stated the altercation between RI #49 and RI #85 that occurred on 6/26/2018 was abuse. ************************* On 8/4/2018 at 3:06 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented Abuse failure to ensure two residents residing on the Dementia unit were free from abuse from other residents: All center staff in-serviced regarding Facility Abuse Policy to include definitions of Abuse, Examples of Abuse, and Interventions to deal with aggressive and/or catastrophic reactions of resident/patients. Implementation of the abuse policy, identification and reporting of Abuse as well as Investigating Abuse. Inclusion of the interpretive guidelines for resident to resident altercations began 8/02/2018 at 1:00PM and will continue until all staff have received training. One hundred twelve of 128 staff members trained on as of 8/03/2018. Additional trainings scheduled for 8/4/2018 to in-service PRN staff, facility has no agency staff. No staff member will be allowed to work without the required training after 8/04/2018. RI# 49 and RI# 84 behavior care plans were reviewed/revised by the Senior DCO on 8/02/2018 to address behaviors and to provide interventions to protect lower cognitive residents from resident to resident altercations similar to those which occurred on 4/28/2018, 5/02/2018, 5/09/2018, 5/25/2018 X 2, and 6/26/2018. New interventions are relayed to the direct care staff by direct one on one in-service by the interim ACU programming manager, LPN. RIs #84 and 49 will be referred to Wellness Solutions for psychiatric evaluation to be conducted on 8/03/2018. Medical evaluation of RI# 49 was conducted on 07/28/2018 by attending physician and on 07/30/2018 by medical director. RI# 85 and 71 will also be evaluated by Wellness Solutions on 08/03/2018. Notes from evaluations are pending receipt from provider. Care plans of RIs will be reviewed for needed changes/ updates after receipt of Wellness Solutions notes. Sr Director of Clinical Operations and RN will review past 30 day documentation of residents currently residing on the Dementia Unit to identify documented behaviors to identify risk for being abused and perpetrating abuse by 8/03/2018. Upon identification of documented behaviors care plans will be reviewed, revised to include interventions to reduce/eliminate to prevent re-occurrences with input from the direct care staff. All allegations reported to state agency beginning on 07/29/2018. On 08/04/2018, Sr Director of Clinical Operations and RN reviewed records (Nurses notes, behavioral notes, weekly notes, daily notes) over the past 30 days to determine if other incidents occurred that should have been reported. Any instances of abuse identified, Interim Administrator will follow and implement reporting per facility Abuse policy and procedure. Interviews will conducted beginning 8/04/2018 with staff and alert residents for identification of any unreported allegations from (MONTH) (YEAR) forward for any resident to resident altercations or abuse of any type. Ongoing programming developed and tailored to individual resident preferences to be offered and implemented by the dementia care staff over all shifts after receiving training by the Interim ACU programing manager. Start training roster 08/04/2018 on the day shift. The interim administrator started on 08/03/2018. She was trained on abuse policies/regulations by Sr Director of Clinical Operations on 08/03/2018. The Sr Director of Clinical Operations assumed the Interim DNS role on 08/03/2018. Both will serve as the Abuse coordinators for the center. Abuse Coordinators Names and Phone numbers are posted throughout the facility. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a E level on 8/4/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 795.

This deficiency was written as a result of the investigation of complaint # AL 921 Based on a re-enactment observation, interviews and record reviews, a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1, failed to obtain the assistance of a second staff member to assist with transferring Resident Identifier (RI) #22, via the Sara Lift 3000 (a stand-up lift) on [DATE]. EI #1 failed to secure the leg straps around RI #22's lower legs before attempting to transfer the resident on [DATE]. Also, EI #1 failed to get a nurse to assess RI #22 for injuries prior to moving the resident with the Sara lift back to bed after the fall on [DATE]. Contrary to the Sara Lift 3000 product manual, EI #1 transferred RI #22 while the resident was in a seated position on the foot rest of the lift. The facility assessed RI #22 to be at risk for falls, requiring a mechanical lift for transfers, as well as, the physical assistance of two staff members to provide weight-bearing support during transfers. Several direct care staff who attended to RI #22's needs on a routine basis, including EI #1, described the resident as being very stiff, nonverbal, difficult to handle, and required a two person assist to transfer safely. RI #22 experienced a witnessed fall while being transferred by EI #1 on [DATE]. EI #1 reported that she did not get the nurse to assess the resident for injuries after the fall. After the resident fell , EI #1 used the Sara Lift to get RI #22 in bed, then went and got another CNA (EI #2) to assist with transferring RI #22 from the bed to the wheelchair, without mentioning that the resident had fallen onto the Sara lift's foot rest platform. Later on [DATE] and again on [DATE], two CNAs (EI #2 and EI #6) reported finding bruises on RI #22's left leg and swelling of the resident's left knee to the Charge Nurse (EI #19). On the evening of [DATE], an order was received for a portable x-ray which revealed an impacted femoral fracture of the left femur. On the morning of [DATE], RI #22 was transported to the local hospital where a repeat x-ray of the left leg was done. According to the hospital's radiology report dated, [DATE] at 7:28 AM, RI #22 was determined to have a highly comminuted (fragmented or broken into pieces) distal left femoral fracture. RI #22's sponsor reported that the resident expired while in the hospital on [DATE] (31 days after sustaining a highly comminuted femur fracture from a fall on [DATE]). A physician, EI #25, reported that RI #22's fractured femur could not be the result of a spontaneous / pathologic fracture; he explained that the resident's fracture was caused by some external force placing pressure on the bones (trauma). This affected RI #22, 1 of 5 residents sampled for falls. This deficient practice placed RI #22's health in immediate jeopardy, as it was likely to have caused serious injury, harm or death to the resident. On [DATE] at 3:47 PM, the facility's Executive Director, the Director of Nursing (DON), and Corporate Nurse Consultant were made aware that the survey team had identified a serious concern in the area of accidents, cited at F323, Immediate Jeopardy (IJ) level, surrounding the incident with Resident Identifier (RI) #22, which occurred on [DATE]. The immediate jeopardy was relieved on [DATE] at 12:10 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. At 12:10 PM on [DATE], the survey team informed the facility staff (Executive Director, Director of Nursing, and Corporate Nurse Consultant) the immediacy of the concern at F323 had been relieved. Findings Include: RI # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], identified RI #22 as having severely impaired daily decision making skills with memory problems. According to the MDS, she was coded as being nonverbal and as rarely if ever being able to make her needs understood or to understand others. She was coded as requiring extensive to total care for Activities of Daily Living. She was coded as needing the physical assistance of two staff members to provide weight-bearing support during transfers. RI #22 was coded as having functional limitations in Range of Motion (ROM) in her upper and lower extremities. The quarterly MDS assessment, with an ARD of [DATE], identified RI #22 as having severely impaired daily decision making skills with short and long term memory problems. She continued to be nonverbal and was unable to make her needs understood or to understand others. In surface-to surface transfer, RI #22 was coded as not steady, only able to stabilize with human assistance. The resident was coded as having functional limitations in ROM in her upper and lower extremities. RI #22's immediate plan of care dated [DATE], and her comprehensive care plan, with a review date of [DATE], revealed that RI #22 had been assessed and determined to be at risk for falls. RI #22's care plan initiated [DATE], and last reviewed on [DATE], identified the focus area of, "I have a physical functioning deficit related to: Self care impairment, Mobility impairment, ROM limitations as evidenced by stiff leg joints, contractures in upper extremities and hands, holds self stiff in her back, non-verbal secondary to aphasia, dementia, CVA (cerebrovascular accident / stroke)." This care plan included the intervention, "Transfer assistance of (Mechanical lift) Date initiated: [DATE]." The facility's "Verification of Investigation" report for RI #22 identified the date / time of occurrence as [DATE] between 7 AM - 12 noon, and listed the date reported as [DATE]. This report documents that: "CNA (Certified Nursing Assistant) reported bruise to left inner thigh to Charge Nurse ." Under the heading, "Provide Summary of Investigative Findings," this report documents: "On Thursday [DATE], LPN (Licensed Practical Nurse) (EI #19) reported the bruising to ADNS (EI #22). She (EI #19) was advised to notify RP (responsible party) and complete the GL123 (an incident report), which were done. DNS (EI #18) was notified and obtained an order for [REDACTED]. Report of fracture received by LPN (EI #20) during the 10pm-6am shift. LPN (EI #20) notified MD on call and the RP shortly after 6 am on [DATE]. Resident was transported to the Emergency Department for evaluation and treatment. Early interview to determine possible cause of bruises and/ or fracture revealed that resident had slid off the bed while secured in the SARA lift harness on Sunday [DATE] during AM transfer to wheelchair. No evidence of injury or pain noted by CNA (EI#1) at that time. After successfully transferring resident to wc (wheelchair) with assistance from (EI #2), CNA ( EI #1) reported to LPN (EI #3) the unusual event. Throughout the rest of Sunday, Monday and most of Tuesday, there was no further events. On Tuesday [DATE] afternoon CNA (EI #23) reported to RN (Registered Nurse) (EI #24) that left knee is swollen. Upon exam and ROM, the resident doesn't demonstrate pain although the knee is reportedly swollen and warm to touch with old bruise noted below and lateral to left knee, no other bruise noted. The RN (EI #24) contributed it to the residents history of arthritis. The same CNA (EI #23) reports to evening nurse, LPN (EI #15) that the knee is swollen. LPN (EI #15) states there was no bruising noted from upper thigh to calf but the knee was swollen consistent her arthritis and resident didn't demonstrate any pain. Resident routine pain medications were given anyway. During AM care on [DATE], CNAs (EI #6) and (EI #2) verbally reported to LPN (EI #19) the presence of a bruise to left inner thigh. LPN (EI #19) reported to oncoming nurse, LPN (EI #20) about bruise. LPN (EI #20) and her CNAs were unaware of any bruises but assessed resident on Thursday morning [DATE] confirmed the presence of the left inner thigh bruise and posterior about knee bruise. LPN (EI #19) then proceeded to report bruises to ADNS (EI #22) ... " The facility's "Verification of Investigation" report for RI #22 contained several undated interview summaries and witness statements from staff who worked with RI #22 during the end of January and first week of February, 2011. The witness statement obtained from EI #2, the CNA who reported the bruises to the Charge Nurse (EI #19) on [DATE], documents: "Sometime after breakfast, before lunch, on Wednesday, did her bathing and noticed a bruise on inner thigh. Reported to the nurse, can not remember which nurse, whoever was on the schedule for our hall. Did not know how bruise happened. Thursday ([DATE]), a.m. noticed bruise behind knee and noticed leg swelling above knee and reported to nurse, (EI #19)." On [DATE] at 11:48 AM, EI #2, the CNA who reported RI #22's bruise to the Charge Nurse (EI #19) on Wednesday ([DATE]), was interviewed. EI #2 said that she saw a bruise on the resident's inner thigh and behind the knee. She described the bruising as not being new and said it was yellow with some dark purple. EI #2 recalled reporting the bruises to the Charge Nurse (EI #19) on Wednesday ([DATE]) and Thursday ([DATE]). According to EI #2, it looked worse; she explained that the swelling on the knee had increased and the bruise on the inner thigh had changed colors. EI #2 said that RI #22 was avoiding bearing weight on the left leg. EI #22 said that RI #22 grimaced in pain when the resident did bear weight. EI #2 recalled that on Thursday ([DATE]), staff thought that something was wrong and that the resident needed to be sent out. EI #6's witness statement documents: "...On Wednesday she (EI #6) and (EI #2) were bathing her (RI #22) and noticed a bruise about the size of her hand on inner thigh, reported this to (EI #19). On Thursday used SARA lift to transfer to shower chair, did shower, no problems during lift, no signs of distress during or after transfer. Bruise looked the same, purple appearance, yellow edge, about size of hand. ..." In an interview on [DATE] at 9:18 AM, EI #6 said that on Wednesday ([DATE]) when she and EI #2 were attempting to get RI #22 up, they noticed a bruise and a little swelling of the knee. EI #6 said that she and EI #2 reported it to EI #19 on Wednesday and Thursday ([DATE] and [DATE]). According to EI #6, RI #22 drew her leg up when they attempted to get her on the lift on Thursday ([DATE]); she described RI #22 as being hard to read because everything made the resident tense up. EI #19's witness statement documents: "(EI #6) came to her (EI #19) on Wednesday and said (RI #22) has a bruise on her leg. Was very busy and forgot about it till shift change and ...told oncoming nurse, (EI #20) to check on the bruise. The next morning, Thursday ([DATE]), when she (EI #19) relieved (EI #20), she (EI #20) confirmed there is a bruise and (EI #19) went to (EI #22), RN, ADNS, to report the bruise. Was instructed to do incident report and get order for an X-ray. Asked the CNAs, (EI #6 and EI #2) if they know how she could have gotten bruise, they (EI #6 and EI #2) did not know of any possible cause." In an interview on [DATE] at 10:44 AM, EI #19 was asked when she first became aware of any type of situation with RI #22. EI #19 answered that a CNA asked her to come to the room and showed her a bruise on the inner left thigh of the resident. EI #19 described the bruise as purple with yellow around the outer edge. She said that the bruise was the size of a tomato. EI #19 recalled that the CNAs brought the bruise to her attention on Wednesday ([DATE]) sometime in the afternoon before 3 PM. EI #19 remembered examining RI #22, wondered if she needed to do an incident report. According to EI #19, she became distracted with the needs of other residents and did not do an incident report. She remembered telling the oncoming nurse (EI #20) about the bruise and asked if an incident report needed to be done. EI #19 did not recall seeing any swelling on Wednesday ([DATE]), but noticed swelling on Thursday ([DATE]). EI #20's witness statement documents: "Wednesday night at shift change (EI #19), LPN asked me to check for a bruise on (RI #22). She asked the CNAs if they have seen a bruise and was told, yes on the inner thigh, greenish in color. Reported bruise to (EI #19), LPN, Thursday a.m. at shift change. On Thursday ([DATE]) night at shift change, 10:00 p.m., she was told...that an x-ray had been done and to check fax for results." On [DATE] at 10:00 AM, EI #20 was interviewed asked when she first became aware of any situation involving RI #22. EI #20 replied that on Wednesday ([DATE]), EI #19 came to her and asked if she knew anything about a bruise on RI #22's left leg. EI #20 said she did not and asked the CNAs if they knew anything about a bruise. According to EI #20, the CNAs did not. EI #20 said that she and the CNAs did a body audit on RI #22 and noticed a bruise on RI #22's left thigh behind the left knee. EI #20 recalled that RI #22's left knee was swollen. She described the bruise on RI #22's inner thigh as greenish in color and the one on the back of the knee as purplish with green blotches. She reported her findings to EI #19 the next morning (Thursday, [DATE]). EI #20 said that on Thursday evening she was instructed to look out for an x-ray report. She received the results around 10:00 PM, which indicated that RI #22 had a fracture. EI #20 said that she faxed the results to the physician around 10 PM, but called the physician's office at 5:30 AM on [DATE]. On [DATE] at 4:00 PM, the Director of Nursing (DON), EI #18, was interviewed and asked when did she first become aware of any incident with RI #22. EI #18 said that she didn't know anything until on [DATE], when she overheard a conversation between the Charge Nurses (EI #19 and EI #20) and the Associate Director of Nursing (ADNS), EI #22. EI #18 said they (EI #19, 20 and 22) were talking about bruises and an incident report. EI #18 said that EI #19 told her that RI #22 had a bruise on her thigh and that the resident's family was being contacted and an incident report would be completed. EI #18 said that she called and got an order for [REDACTED]. EI #18 recalled that the nurse got the x-ray results, and that on Friday ([DATE]) at 8 AM, she learned that RI #22's leg was broken and that the resident had been sent out to the hospital. According to EI #18, Friday morning after the stand-up meeting, she and the managers met to discuss the incident with RI #22. EI #18 said that no one in attendance knew anything about any incident with RI #22; so, she got the work schedule and started calling staff to determine if anyone knew anything about an incident with RI #22. EI #18 said that she called EI #1, a CNA, who told her about an incident on [DATE], where RI #22 slid out the bed. In a follow-up interview on [DATE] at 10:00 AM, EI #18 stated that RI #22's fracture was not considered an injury of unknown origin because she thought that the fall from the lift may have been the cause of the fracture. She said that it was possible that the fracture could have occurred as a result of the fall and was not detected until several days later. Review of the document titled "Radiology Report", for RI #22, dated [DATE], revealed " ...Results: The femur shows osteoporosis. There is a impacted Supracondylar fracture of the femur. The remainder of the femur is intact. Osteoporosis is present. Conclusion: Impacted left femur fracture as described." A review of a document titled, "South Baldwin Medical Center ...Radiology Report" revealed: " ...Findings: Comminuted fracture of the distal left femur with a transverse fracture through the metaphysic and a vertical component extending inferiorly splitting the femoral condyles. There are at least three and possibly for (four) fractures fragments. On the lateral view there is questionably fracture of the tibial plateau. Fibula appears intact. Impressions: Highly comminuted distal left femoral fracture ..." The facility's investigation report titled, "Verification of Investigation," contained an interview summary obtained from EI #1, the CNA who provided care to RI #22 on [DATE]. EI #1's interview summary documents: "Readily described an even (event) from Sunday [DATE] when she was getting resident up to wheelchair. Resident was secured in the SARA lift harness and sitting on the side of the bed. ( EI #1) moved toward from (front)of Sara lift to get remote, resident suddenly slipped off of bed. Resident landed with legs apart but out straight and under the shin guards with her bottom on the foot platform. She was still suspended in the harness. (EI #1) reports raising the Sara lift slightly ...and lowering the bed until she had enough room to get resident onto bed. She then asked CNA ( EI #2), who was more familiar with the resident to assist putting her to (into) wheelchair with the lift. No obvious injuries or demonstration of pain noted. She stated she went to find the nurse (EI #19) but couldn't so she told the other charge nurse ( EI #3) on the hall what happened. 'I didn't think of it as a fall then, like I do now or I would have gotten the nurse first. But I knew I had to report the unusual change in level in case something showed up later'." On [DATE] at 4:35 PM, an interview was conducted with EI #1, the CNA who reported to the DON (EI #18) on [DATE], an incident involving RI #22 sliding off the bed on [DATE]. During the interview, EI #1 was asked to describe the events that occurred on [DATE], at around 9:30 AM, in regards to RI #22. EI #1 stated that she was getting the resident up from bed. She put the harness on the resident and went around the lift to get the remote. According to EI #1, the lift was locked. She stated that in one sudden movement RI #22 slipped of the edge of the bed and landed on the foot rest platform of the lift. EI #1 said that RI #22's bottom was on the foot rest and her legs went underneath the shin protectors. RI #22's legs were straight out in front of her and split around the pole to the lift. RI #22's shoulders were observed to still be in the sling over the resident's head. RI #22's right hand was still holding onto the handle of the lift, but her left hand was not. RI #22 did not indicate that she was in any kind of pain. EI #1 described the resident's facial expression as looking like she was surprised. EI #1 lowered the resident's bed as low as it would go and transferred the resident via the Sara lift back to bed, with RI #22 still in a seated position on the foot rest of the lift, with the resident's legs underneath the shin protectors and outstretched in front of her (RI #22). Once in position, EI #1 slid RI #22 back into bed. After the resident was back in bed, EI #1 left the room and got EI #2 (a CNA) to assist her in transferring the resident from the bed to the wheelchair. EI #1 stated she did not remember if she told the EI #2 (the other CNA) about RI #22's fall but that she remembers the transfer was successful. Then, EI #1 said that she checked RI #22 for injuries and was unable to see any. EI #1 stated that after the resident was up in the wheelchair she then went and told EI #3, a Licensed Practical Nurse (LPN), about the fall. When asked what the nurse said or did when told about the fall, EI #1 responded that the nurse did not say anything and that in fact she felt like the nurse (EI #3) either did not hear her or did not process what she (EI #1)was telling her (EI #3). EI #1 stated that because she felt like the nurse (EI #3) did not hear her, she told another nurse (EI #15) a couple of days later. EI #1 was asked if she reported this incident to the CNA who relieved her and/or the oncoming nurse. She answered that she did not because she had already reported it to the nurse on her shift. EI #1 stated that over the next couple of days, she kept checking on RI #22 to see how she was doing. EI #1 was asked how many staff members were needed to safely transfer RI #22. She stated they (staff) usually tried to do lift transfers with two people present but sometimes it was done with only one staff member. EI #1 stated that she told a fell ow staff member (EI #23), before RI #22's fall, that they (CNAs) should not transfer the residents, especially RI #22 by themselves because it was not safe for the resident. EI #1 was asked if she thought that the fall on [DATE], could have been prevented if two staff member were present. She answered that if two staff members were present during the transfer that it could have prevented the resident's fall. EI #1 stated that she had not gotten the resident out of bed before, but said that she usually assisted other staff members in getting the resident into bed. She stated that she was really nervous about having to transfer the resident with the lift by herself because the resident was very stiff. She stated she would have to pull the resident's arms to get them on the handles and she would have to take her knees and press up against the resident's legs to get them secured in the lift. She commented that it would have been safer for the resident if two people had assisted with the transfer. EI #1 was asked did she feel that the fall on [DATE], could have caused RI #22's fracture. She replied that she did think the resident may have sustained the fracture during the fall. She felt it could have caused a small injury that probably got worse due to repeated movement via the Sara lift. EI #1 stated that she heard the resident was found to have bruising on her breast when she was admitted to the hospital and that she thought that may have been caused by the sling when she fell . On [DATE] at 5:45 PM, EI #1 was asked to show the surveyors how the resident was positioned after her fall on [DATE] and what position she was in when the lift was used to return the resident to bed. EI #1 demonstrated placing the belt around RI #22's belly, padding under the resident's arms and attaching the strap to the tabs on the lift. Then, EI #1 demonstrated that she placed the resident's feet underneath the shin (leg) padding. The surveyor asked EI #1 what the leg straps were used for. EI #1 responded that at the time of the fall, the leg straps were not secured around RI #22's legs. She explained, "I didn't lock the seat belt around her legs" because RI #22's legs are "too stiff". The document titled, "Sara 3000 Operating and Product Care Instructions, dated ,[DATE], page 4 documents: "...when lifting from a seated position in bed a second attendant should support the patient if the patient lacks sitting balance." Page 8 of this product manual documents that the lower leg straps are accessories "to ensure the lower parts of the patient's legs stay close to the knee support. ..." Page 11 of this manual documents: " ...Caution: The patient's feet should always remain in full contact with the foot support. When lifting, check to ensure that the patient's feet do not lift from the support or floor. If this should happen inadvertently lower the patient immediately until full foot contact with the support or floor is achieved." In an interview on [DATE] at 9:00 AM, EI #3, an LPN, was asked to describe the incident that occurred on [DATE], involving RI #22. EI #3 responded that she and another nurse worked on the hall together on [DATE]. She stated that she did not become aware of the incident with RI #22 slipping off of the bed until sometime after [DATE]. EI #3 could not recall EI #1 reporting the incident involving RI #22; she explained that if the fall had been reported to her, she would have immediately gone down to the resident's room and assessed the resident. She stated she also would have documented the incident. According to EI #3, a resident should not be put back to bed after a fall because it is not safe to move the resident because the resident may have been seriously injured during the fall. EI #3 was asked if she thought that RI #22 could have sustained the fracture to her femur during the fall on [DATE]. She answered that it was possible, and that the fracture just was not discovered until later. She stated that if the fall had been reported on the day of the fall, then the fracture could have be found earlier. EI #3 clarified that reporting this incident was very important because RI #22 was non-verbal and was unable to tell anyone if she was experiencing pain. On [DATE] at 4:10 PM, EI #15 (an LPN) was asked if EI #1 ever reported any incidents or accidents involving RI #22. She stated that EI #1 did not tell her anything about RI #22 being dropped from a lift. EI #15 stated that EI #1 told her about the resident having a swollen knee and that she felt the resident should be switched from the Sara lift (a stand-up lift) to the Hoyer lift (Marisa Lift). EI #15 was asked what RI #22 needed to ensure a safe transfer. She responded that it was her understand that the leg straps on the lift had to be used to ensure leg stability and that the resident required the assistance of two staff members during a transfer for her safety because she was so stiff and hard to handle. EI #15 commented that she always told the CNAs to use two people when transferring RI #22. EI #15 was asked what a staff member should have done if he / she witnessed a resident slide off the side of the bed and land on the foot rest of a lift. She responded that the nurse should have been notified immediately so that the resident could have been assessed prior to being moved. EI #15 was asked if it was safe for a resident to be transferred prior to being assessed by a nurse. She responded that a CNA should not move the resident in case there is a serious injury that cannot be seen. She further stated that moving the resident could have compromised the health and safety of the resident. EI #15 was asked if she thought it was possible that RI #22 could have sustained a fracture during the fall on [DATE], which wasn't discovered until later. She responded that it was possible, and that in fact, everyone involved felt that the resident sustained [REDACTED]. On [DATE] at 7:45 AM, an interview was conducted with EI #16, the CNA who relieved EI #1 on [DATE] at 11:00 PM. EI #16 was asked if EI #1 (off-going CNA) or any other staff member reported RI #22's fall to her. She responded that she received report from EI #1, but was not told anything about RI #22 having a fall that day. EI #16 was asked what type of lift was needed to transfer RI #22 and how many people were needed to transfer the resident. She answered that she used a Sara lift and got a partner to help with the transfer of RI #22. She also stated that CNAs always have to make sure the legs straps are fastened because RI #22 never keeps her legs straight and the legs straps helps to prevent sliding. According to EI #16, if the straps were not attached, RI #22 could have slipped because she was not able to put weight on her legs. EI #16 was asked what should be done after a resident falls. She responded that staff should not move the resident until the resident has been assessed by a nurse. In an interview on [DATE] at 9:18 AM, EI #6 (a CNA who regularly provided care to RI #22) was asked how many staff members were needed to transfer RI #22 safely. She answered that even though the lift could be operated with only one person, RI #22 needed two staff members to transfer her because the resident had poor balance and was very stiff. On [DATE] at 11:48 AM, an interview was conducted with EI #2, the CNA who assisted EI #1 with transferring RI #22 from the bed to the chair after the resident's fall on [DATE]. EI #2 was asked how many staff members were needed to safely transfer RI #22. She responded that they (CNAs) never transfer RI #22 with just one person because the resident stiffens up and is very difficult to move. EI #2 said that EI #1 knew the resident needed a two person assist. According to EI #2, everyone knew that RI #22 was a two person assist. EI #2 was asked if she would have considered the resident sliding from bed and landing on the foot rest of the lift to be a fall. She stated she would consider that to be a fall. She was asked what a staff member should do if they witnessed a resident fall. EI #2 responded that if a fall was witnessed, the staff member should immediately get the nurse, let the nurse assess the resident for injuries, and if the nurse says it is ok to move the resident then the resident should be transferred via the Marisa lift not the Sara lift. EI #2 explained that the Sara lift (a stand-up lift) should not be used because it requires the resident to bear weight. EI #2 was asked why it is important to report a fall. She responded that it is important to report a fall because a resident may have broken something or may have a head injury or internal injury that would require treatment or compromise the resident's health. On [DATE] at 10:00 AM, an interview was conducted with EI #20 (an LPN who noticed RI #22's bruises during a body audit on [DATE]). EI #20 was asked how many staff members are needed to safely transfer RI #22. She responded that based on the weight of RI #22, the resident required a two person assist. EI #20 was asked if she felt that RI #22 could have sustained a fracture during her fall on [DATE]. She responded that she thought the fall could have caused the fracture because nothing else was reported to have happened to the resident between [DATE] and [DATE]. On [DATE] at 10:44 AM, an interview was conducted with EI #19 (an LPN who received a report of bruising on RI #22 from two CNAs on the day shift of [DATE]). EI #19 was asked how many staff members were needed to safely transfer RI #22. She responded that two people were needed to transfer RI #22. EI #19 explained that RI #22 would stiffen up, and that she always tells her CNAs to use a two person assist to ensure patient safety. EI #19 was asked if she felt that RI #22 could have sustained a fracture during her fall on [DATE]. She responded that with osteoporosis, it was possible that the resident could have sustained a fracture during the fall on [DATE], which did not show up until [DATE] or [DATE]. An interview was conducted on [DATE] at 11:00 AM with EI #21 (an LPN). EI #21 was asked if RI #22 slid off of the bed and landed on the foot rest of the lift would that have been considered a fall. She affirmed that if a resident slid off the bed and landed on the foot rest of the lift that it would have been considered a fall. EI #21 added that the CNA should have immediately reported the incident to the charge nurse. She stated that the charge nurse should have completed a head to toe assessment on the resident, completed an incident report, and reported the incident to the patient's physician and sponsor. EI #21 was asked what should a CNA do after he or she witnesses a fall. She responded that the CNA should not move the resident, should immediately call for help and wait for the nurse to assess the resident before moving the resident. EI #21 was asked why it is important to have a nurse assess the resident after a fall before attempting to move the resident. She responded because the staff member may not know if the patient is injured or not and if they move them then they may cause additional harm. The surveyor asked EI #21 why was it important in this situation for the CNA involved to have reported the resident's fall and ensure that the resident was assessed by a nurse. She responded that if this had been reported, then the resident's fracture may have been identified sooner because the nurse would have watched the resident closer and may have gone ahead and gotten the order for an x-ray. EI #21 was asked if she thought that RI #22's fracture could have occurred during the fal